HX641 14376 
RC87.B93  A  text-book  of  first 


RECAP 


ColumtJia  WLni\)tv9iitf 
in  tfje  Citp  of  ^to  Iforfe 

CoUcge  of  ^fjpsicianf;  anb  burgeons 


S^eference  Hibrarp 


^^mMmmm 


Digitized  by  tine  Internet  Arciiive 

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http://www.archive.org/details/textbookoffirstaOOburn 


A  TEXT-BOOK 


FIRST  AID  AND  EMEEGENCY 
TREATMENT 


BY 

A.  C.   BURNHAM,  M.D. 

MEDICAL  CORPS,  U.  S.  R. 

INSTRUCTOR  IN  SURGERY  IN  THE  POLYCLINIC  HOSPITAL,  NEW  YORK  CITY; 

ATTENDING  SURGEON,  DEPARTMENT    OF  SURGERY,    VANDERBILT 

CLINIC,   COLLEGE  OF  PHYSICIANS   AND   SURGEONS, 

NEW  YORK  CITY 


ILLUSTRATED  WITH   160  ENGRAVINGS  AND  2  PLATES 


LEA   &   FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1917 


Copyright 
LEA  &  FEBIGER 

1917 


3  ^j5 


PREFACE. 


In  the  preparation  of  this  book  the  author  has  kept  in 
mind  the  requirements  of  both  the  untrained  first-aid  worker 
and  the  advanced  student  who  may  be  expected  to  practise 
the  art  under  the  conditions  of  modern  warfare. 

In  its  essentials  the  practice  of  first  aid  is  the  same  whether 
the  worker  is  surrounded  by  the  conveniences  of  a  civihzed 
community  or  is  in  the  wilderness  or  upon  the  battlefield. 
In  any  of  these  places  emergencies  may  occur  which  in  the 
absence  of  skilled  medical  aid  require  immediate  volunteer 
treatment,  the  character  of  the  services  being  determined 
by  the  skill  of  the  volunteer  and  the  available  medical  and 
surgical  supplies. 

This  book  is  intended  to  so  train  the  volunteer  assistant 
that  when  the  emergency  occurs  he  may  be  able  to  apply 
the  principles  of  first  aid  to  the  case  at  hand. 

In  addition  the  volume  has  been  made  complete  in  many 
small  details,  so  that  the  advanced  worker  may  find  it  a 
reliable  reference  book  for  both  field  and  hospital  work,  and 
the  camper  and  yachtsman,  in  the  absence  of  a  physician, 
may  find  in  it  sufficient  information  to  enable  him  to  assume 
temporary  care  of  the  sick  and  injured. 

In  teaching  first  aid  in  the  conventional  course  of  six 
or  eight  lessons,  it  has  not  been  the  author's  custom  to 
attempt  to  cover  the  entire  book.  Such  a  plan  being  imprac- 
ticable, he  has  endeavored  to  fix  the  principles  of  treatment 
thoroughly  in  the  minds  of  the  students,  so  that  the  interest 
thus  aroused  will  lead  them  to  a  further  study  of  .the  lesser 
details. 


IV  PREFACE 

In  coiidiictinij  his  courses  tlio  author  has  found  it  advan- 
tajxeous  to  c'onil)ine  a  part  of  the  anatomy  and  jihysiolofjy 
with  each  lecture  on  treatment.  Thus  the  anatomy  of  the 
hones  and  the  joints  is  given  in  the  lecture  on  fractures  and 
dislocations,  and  the  anatomy  and  ])hysiology  of  the  circula- 
tion is  <i;i\i'n  in  coiuicction  with  hemorrhage. 

Complete  instruction  on  l)andaging  an<l  transi)ortation  can 
be  given  only  to  those  who  are  able  to  devote  considerable 
time  to  this  subject.  This  is  intended  more  especially  for  the 
Sanitary  Corps  of  the  Army  and  Navy,  organizations  of 
Boy  Scouts,  nurses'  aids,  and  others  who  expect  to  ([ualify 
for  similar  duties. 

The  character  of  the  text  deviates  considerably  from 
that  of  many  of  the  older  books,  the  student  being  drilled  in 
the  principles  of  diagnosis  and  treatment  instead  of  being 
limited  to  didactic  rules  of  procedure  in  individual  cases. 
The  modern  methods  of  treatment  have  been  given  .special 
jjrominence,  though  the  older  methods  of  proven  worth  have 
not  been  omitted.  New  and  untried  remedies,  the  value  of 
which  is  still  largely  problematical,  have  not  been  discussed. 

This  book  is  based  upon  an  experience  of  many  years  in 
tlie  emergency  wards  of  some  of  the  largest  New  York  Hos- 
pitals and  on  wide  experience  as  a  teacher  of  first  aid.  It 
has  two  aims:  the  first,  and  less  important,  is  the  education 
of  the  student  in  first  aid;  and  the  second,  of  considerably 
greater  importance,  is  the  alleviation  of  suft'ering  and  the 
saving  of  life. 

A.  C.  B. 

Xkw  Yohk,  1917. 


CONTENTS. 


CHAPTER  I. 

General  Principles  of  First  Ain. 

Equipment  and  Supplies 22 

The  Organization  of  First  Aid 25 

CHAPTER  II. 

Anatomy  and  Physiology. 

The  Bones 27 

The  Skeleton 27 

The  Head 27 

The  Mandible 30 

The  Trunk 31 

The  Spinal  Column 31 

The  Ribs 31 

The  Pelvis 31 

The  Upper  Extremity 32 

The  Clavicle ' 32 

The  Scapula 33 

The  Humerus 33 

The  Forearm 33 

The  Carpus 33 

The  Metacarpus 33 

The  Phalanges 33 

The  Lower  Extremity 34 

The  Femur 35 

The  Patella 35 

The  Leg 36 

The  Tarsus 36 

The  Metatarsus 36 

The  Phalanges 36 

The  Joints 36 

The  Muscles 40 


VI 


CONTEXTS 


Tlic  B1(kk1  and  ("ircvilalion 

Tlic  HIdo.I    .      . 

The  Heart    .      . 

The  Arteries 

The  C'apiUaries 

The  Veins 

The  Circulation 
The  Nervous  System 

The  Brain    . 

The  Spinal  Cord 

The  Nerves 

The  Action  of  the  Nerves 
'The  Respiratory  System 

The  Nose     . 

The  Larynx 

The  Trachea 

The  Bronchi 

The  Lungs  . 

Respiration 
The  Abdomen 

The  Alimentary  Canal 

The  Stomach 

The  Liver    . 

The  Kidneys 

The  Bladder 

The  Peritoneum 

The  Reproductive  Organs 


43 
43 

4r^ 
4G 
48 
49 
49 
51 
53 
54 
54 
54 
58 
58 
59 
59 
59 
59 
GO 
61 
61 
61 
61 
64 
64 
64 
64 


CHAPTER  III. 

Wounds  and  Wound  Infection. 

Contusions 65 

Wounds 66 

Hemorrhage 67 

Capillary  Hemorrhage 67 

Venous  Hemorrhage 68 

Arterial  Hemorrhage 68 

Methods  of  Controlling  Hemorrhage 68 

1.  Direct  Pressure .69 

2.  Elevation      ...                  71 

3.  Heat  and  Cold 71 

4.  The  Tourniquet       ...            71 

5.  Styptics 74 


CONTENTS  VII 

Infection  and  Suppuration 74 

Bacteria 74 

■   Asepsis  and  Antisepsis 77 

Asepsis  by  Heat          77 

Disinfectants 78 

Antiseptics 78 

Surgical  Preparation  of  the  Hands 79 

The  Repair  of  Wounds 79 

Chnical  Course  of  Infected  Wounds 81 

Summary  of  the  Treatment  of  Wounds 82 

Clean  Wounds 82 

Infected  Wounds 84 

CHAPTER  IV. 
BANDAGING. 

The  Triangular  Bandage 86 

Wounds  of  the  Scalp 87 

Wounds  of  the  Forehead 87 

Wounds  of  the  Chest 88 

Wounds  of  the  Hip 88 

Wounds  of  the  Upper  Arm 88 

Wounds  of  the  Forearm,  with  Broad  Sling  for  Arm     ...  88 

Wounds  of  the  Hand •  .      .      .  89 

Wounds  of  the  Thigh,  Knee  or  Leg 89 

Wounds  of  the  Foot 89 

To  Secure  SpUnts "  .      .      .      .  89 

To  Improvise  a  Tourniquet 89 

The  Four-tailed  Bandage 89 

Wounds  of  the  Scalp 90 

Wounds  of  the  Chin 90 

The  RoUer  Bandage 90 

To  Roll  a  Bandage 91 

Application  of  a  Bandage 91 

Figure-of-eight  Bandage 93 

Spiral  Reverse  Bandage  of  the  Forearm 93 

Spica  of  the  Shoulder 94 

Spica  of  the  Groin 95 

Spica  of  the  Buttock 95 

The  Spica  of  Both  Groins .  96 

Figure-of-eight  of  the  Elbow 96 

Figure-of-eight  of  the  Knee    . 97 

Finger-tip  Bandage 97 


viii  cox  TEXTS 

The  Roller  Bandago — 

Gauntlet  Baiulatie ...  99 

FijiuiT-of-oijiht  of  Ankle  and  Foot  100 

Fisni-e-of-eight  of  the  Heel     ....            101 

Recurrent  Bandage  of  the  Toes  ......  101 

Recurrent  Bandage  of  the  Stump 101 

Figure-of-eight  of  the  Leg 101 

Eye  Bandage 102 

Ear  Bandage 103 

Head  Bandage 103 

Recvu'rent  Bandage  of  the  Head 104 

Circular  Bandage  of  the  Neek 105 

Barton's  Bandage 105 

Bandage  of  the  Neck  and  Axilla 106 

Bandage  of  the  Chest  and  Axilla 106 

Figure-of-eight  Bandage  of  the  Chest 107 

Breast  Bandage 107 

Circular  Bandage  of  the  Chest  and  .Vbdomen 109 

The  Velpeau  Bandage 110 

CHAPTER  V. 

Fractures  and  Dislocations. 

Fractures Ill 

Symptoms  of  Fracture 113 

Union  of  Fractures 118 

Treatment  of  Fracture 118 

Special  Fractures 121 

Fracture  of  the  Skull 121 

Fracture  of  the  Spine 121 

Fracture  of  the  Nose 123 

Fracture  of  the  Jaw         123 

Fracture  of  the  Dental  Margin  of  the  Jaw      ....  124 

Fracture  of  the  Collar  Bone 125 

Fracture  of  the  Ribs 125 

Fracture  of  the  Arm 126 

Fracture  of  the  Elbow 127 

Fracture  of  the  Forearm 128 

Fracture  about  the  Wrist 130 

Fracture  of  the  Hand 130 

Fracture  of  a  Finger 131 

Fracture  of  the  Thigh 131 

Fracture  of  tlie  Knee-ca]) 131 


CONTENTS  IX 

Fractures — 

Special  Fractures — 

Fracture  of  the  Leg 1^>2 

Fracture  of  the  Ankle 1-53 

Fracture  of  the  Foot  and  Toes 135 

Compound  Fractures 135 

Dislocations 135 

Symptoms 130 

Treatment ' 136 

Habitual  Dislocation 136 

Persistent  Dislocation 136 

Special  Dislocations 137 

Dislocation  of  the  Spine 137 

Dislocation  of  the  Clavicle 138 

Dislocation  of  the  Shoulder 138 

Dislocation  of  the  Elbow .  140 

Dislocation  of  the  Wrist 140 

Dislocation  of  the  Fingers 141 

Dislocation  of  the  Jaw 141 

Dislocation  of  the  Hip 143 

Dislocation  of  the  Patella 143 

Dislocation  of  the  Knee 143 

Dislocated  Meniscus 143 

Dislocation  of  the  Ankle  and  Foot 143 

Dislocation  of  the  Toes 143 

Sprains 144 

Sprained  Ankle 145 

Sprained  Wrist 146 

Sprained  Fingers 146 

Sprained  Knee 146 

Sprained  Back 146 

Wounds  of  Bones  and  Joints 147 

Bullet  Wounds  of  the  Bones  and  Joints 147 

CHAPTER  VI. 

Miscellaneous  Injuries. 

Burns 149 

Severe  Burns 152 

Chemical  Burns 153 

Injuries  Caused  by  Cold 154 

Exposure  to  Cold 154 

Frost-bite 155 


COXTENTS 


Injurios  Causod  by  Islcctririty 
Bite  Wounds 

Di-K  Bito      .      . 

llydropliohia 

Snake  Bite  . 

Insect  Bites 

Tetanus 


157 
159 
150 
l(j() 
IGl 
103 
103 


CHAPTER  VII. 

General  Injuries. 

Shock 1()G 

Fainting IGS 

Sunstroke 170 

Heat  Exhaustion 173 

Exjjosure  to  Extreme  Cold 174 

Unconsciousness 174 

Hysterical  Unconsciousness 17G 

CHAPTER  VHI. 

Suffocation. 

Artificial  Respiration 179 

Choking 184 

Drowning 184 

Suffocation  by  Smoke    .    , 187 

Asphj'xiation  bj^  Illuminating  Gas 187 

Asphyxiation  by  Irritant  Gases 189 

Asphyxiation  bj'  Gas  in  the  European  War 189 


CHAPTER  IX. 

Regional  Injuries. 

Head 193 

Wounds  of  the  Scalp 193 

Infection  of  the  Scalp 194 

Concussion  of  the  Brain    .      .  ....  .  194 

Intracranial  Injury       .      .  .  195 

Eye 197 

Contusion  of  the  Eye 197 

W^ounds  About  the  Eye     .      .  198 

Foreign  Body  in  the  Eye  .  198 


CONTENTS  '  XI 

Ears 199 

Boxer's  Ear 199 

Foreign  Body  in  the  Ear 200 

Nose 200 

Foreign  Body  in  the  Nose 200 

Bleeding  from  the  Nose 200 

Mouth 201 

Wounds  of  the  Mouth 201 

Hemorrhage  from  the  Mouth 201 

Hemorrhage  from  the  Lungs 202 

Hemorrhage  from  the  Stomach 202 

Internal  Hemorrhage 202 

Foreign  Bodies  in  the  Throat 203 

Chest 204 

Contusion  of  the  Chest 204 

Wounds  of  the  Chest 204 

Abdomen 205 

Contusion  of  the  Abdomen 205 

Wounds  of  the  Abdomen 207 

Strangulated  Hernia 207 

Rectum,  Bladder  and  Reproductive  Organs 208 

Injuries  to  the  Extremities 208 

Crushing  Injuries 208 

Division  of  the  Tendons 210 

Division  of  Nerves 210 

Foreign  Body 211 

Muscle  Strain 211 

Rupture  of  a  Muscle -  212 

Bhsters  and  Abrasions  of  the  Feet    : 212 

Ingrowing  Toe-nails • 213 

Splinter  Beneath  the  Nail 213 

Blood  Bhsters 213 

CHAPTER  X. 

Poisoning. 

Symptoms 215 

General  Treatment 215 

Antidotes 219 

Special  Poisonings 221 

Caustic  Acids 221 

Caustic  Alkahes 222 

Carbolic  Acid 222 


Xll  ^  COX'I'hWTS 

Siiecial  Poisonings — 

Opium 223 

Chloral 223 

Strychnin 224 

Belladonna 224. 

Bichloride  of  Mercury 224 

Acute  Alcoholism 225 

Chloroform  and  I'^ther 227 

IMushroom  Poisoning 227 

Ptomain  Poisonin<i 227 

Table  of  Poisons  and  Antidotes 228 

CHAPTER  XI. 
Emergency   Treatment  of  Disease. 

Fever 230 

Chills 231 

Convulsions 233 

Epilepsy  or  Fits 233 

Convulsions  in  Children 235 

CHAPTER   XII. 

Common  Emergencies. 

Headache 236 

Toothache 237 

Neuralgia 238 

Earache 239 

Conjunctivitis .      .  239 

Stye 240 

Boils 240 

Carbuncle 242 

Hiccough ....  242 

Sore  Throat 242 

Colds 243 

Hoarseness 243 

Spasmodic  Croup 244 

Diphtheritic  Crou]) 246 

Cough 246 

Shortness  of  Breath 246 

Indigestion 247 

Nausea  and  Vomiting 247 

Colic 248 


CONTENTS  xiu 

Appendicitis 248 

Diarrhea 249 

Hemorrhoids 250 

PainfulJoints 251 

Painful  Muscles 252 

Warts  and  Moles 252 

Ivy  Poisoning :      .      .      .      .  252 

CHAPTER   XIII. 

Transpohtation. 

Litter  Transportation 256 

Litter  Drills 257 

The  Loaded  Litter 261 

To  Pass  Obstacles 264 

To  Improvise  a  Litter 266 

Transportation  without  Litter 268 

To  Lift  a  Helpless  Patient 268 

To  Carry  Across  the  Back 269 

The  Travois 269 

Wheel  Transportation 270 

The  Ambulance 270 

CHAPTER  XIV. 

Nursing  and  Technic. 

Nursing  Methods .  275 

To  Prepare  the  Room 275 

To  Make  the  Bed 276 

To  Change  the  Sheets 276 

Care  of  the  Skin 276 

Bed-sores     . 277 

Temperature 277 

Pulse      . 279 

Respiration 279 

Tongue 280 

Baths  and  Bathing 280 

Sponge  Baths 281 

Alcohol  Sponge 281 

Tub  Baths 282 

Ice  Baths 282 

Hot  Packs 282 

Sweat  Baths 283 


XIV 


CONTENTS 


Baths  ami  Batliinp  — 

luKit-hallis   .      . 

Sitz  Huths    . 

Medicated  Baths 
External  Apphoations 

The  Apphcatiuii  of  Heat 

Hot  Compresses 

Stupes    . 

Turpentine  Stupes 

Flaxseed  Poultice 

jNIustard  Plaster 

Cold  Compresses 

The  Ice-bag 
Covmter-irritants 

Electricity    . 

The  Cautery 

Cuppinp 

Tincture  of  lodin 

Liniments 

Ointments    . 
Sterilization  . 

Instruments 

Solutions 

Glassware  and  (.!r;uiit( 

Towels  and  Dressings 

Hands  and  Skin 

Rubber  Gloves 

Diet 

Drugs 

Stimulants  . 

Sedatives 

Cathartics    . 

Anodynes 

Disinfectants  and  Antiseptics 
Boric  Acid 
Bicarbonate  of  Soda 
Bichloride  of  Mercury 
Carbolic  Acid  (Phenol) 
Tincture  of  lodin 

Emetics 


FIRST  AID  AND  EMERGEINCY  TREATMENT. 


CHAPTER   I. 
GENERAL  PRINCIPLES  OF  FIRST  AID. 

The,  present  conception  of  first  aid  defines  the  term  as 
that  expert  assistance  which  may  be  given  by  a  layman  in 
the  emergency  treatment  and  transportation  of  the  sick  or 
injured.  It  should  include  the  relief  of  pain,  the  prevention 
of  further  harm  Avhenever  possible,  and  the  recognition  of 
the  seriousness  of  the  condition  present. 

In  its  broadest  sense,  first  aid  may  be  given  by  the  patient 
himself;  by  a  layman  with  or  without  special  training;  by  a 
professional  nurse;  or  by  a  physician.  Ordinarily,  the  usage 
of  the  term  is  limited  to  "that  assistance  which  may  be 
given  by  anyone  who  has  had  a  certain  amount  of  special 
training  in  the  principles  of  first  aid."  It  is  in  the  latter 
sense  that  the  subject  will  be  treated  in  these  pages. 

The  relief  of  pain  is  of  the  utmost  importance.  Pain  not 
only  causes  the  patient  discomfort,  but  is  an  actual  source 
of  danger  to  life.  It  has  been  shown  in  animals  that  if,  in 
addition  to  the  primary  injury,  an  animal  is  allowed  to 
suffer  severe  pain  for  a  long  period,  the  general  symptoms 
of  shock  and  prostration  become  progressively  more  severe, 
often  ending  in  death.  If  the  pain  due  to  the  original  injury 
is  made  less  by  the  administration  of  opiates  or  by  the 
protection  of  the  injured  part  the  tendency  is  toward 
recovery. 

The  prevention  of  further  harm  is  equally  important.  In 
a  patient  who  has  had  a  moderate  hemorrhage  it  is  at  once 
apparent  that  recovery  will  be  made  easier  if  further  hem- 
2 


18'  aEXKh'M.    l'h'l.\Cll'IJ-:s   OF   FIRST   AID 

orrhage  is  ])r('\rrite(l;  in  tlic  case  of  a  wound  it  is  solt'-cvident 
that  care  should  he  taken  that  the  wound  does  not  l)econie 
infected;  wliik'  a  sinii)le  fracture  is  made  much  worse  if  a 
ja,i;<jed  end  of  the  hone  is  allowed  to  jaenetrate  the  skin. 

The  ahility  to  recofj;nize  the  sex^erity  of  the  injury  or  the 
seriousness  of  the  attack  of  illness  is  <j;reatly  to  be  desired 
in  those  who  may  be  recinired  to  i)ractise  first  ai<l,  not  only 
because  it  gives  some  indication  of  the  treatment  necessary, 
but  also  because  it  enables  the  first-aid  worker  to  come  to  a 
conclusion  as  to  how  important  it  is  to  secure  ])rofessional 
aid  at  once  and  to  determine  the  necessity  for  the  ai)i)lica- 
tion  of  relief  measures  on  the  spot,  or  the  ad^•isability  of 
transportation  to  a  more  suitable  location. 

For  example,  we  might  suj^pose  that  a  man  had  been  riui 
over  and  was  lying  in  the  middle  of  the  street.  If  the  injury 
is  slight,  a  scalp  wound  or  a  fractured  wrist,  he  could  be 
allowed  to  walk  to  a  more  convenient  place  to  wait  for  a 
surgeon;  or  he  might  even  walk  to  the  nearest  physician's 
office  or  hospital.  If  the  injury  is  more  severe,  a  fractured 
thigh,  for  example,  and  is  associated  with  considerable 
shock,  it  is  important  that  he  be  transported  within  a  rea- 
sonably short  time  to  a  location  where  he  may  be  kept  warm 
and  comfortable;  but  to  attempt  to  carry  him  a  long  dis- 
tance is  not  justified.  If  the  injury  is  still  more  severe,  such 
as  a  fracture  or  dislocation  of  the  spine,  an  attempt  at 
removal  before  all  the  necessary  appliances  and  expert  help 
is  at  hand  would  be  very  dangerous.  Such  a  patient  should 
be  left  where  he  has  fallen  until  expert  help  has  been  secured. 
In  this  last  case  the  occasion  might  arise  where  it  would 
be  wiser  to  remove  the  patient,  even  at  a  considerable  risk, 
because  the  conditions  might  be  such  (for  example,  exposure 
to  cold  and  rain  for  a  long  period  while  waiting  for  a  sur- 
geon) that  the  danger  of  remo\'al  would  be  less  harmful 
than  inactivity.  In  such  cases  the  trained  stuflent  in  first 
aid  will  be  able  to  give  expert  assistance  while  the  untrained 
volunteer  may  only  accomplish  harm. 

From  the  foregoing  it  is  apparent  that  the  student  of  first 
aid  requires  a  certain  amount  of  knowledge  and  a  consider- 
able degree  of  judgment.    F'ollowing,  as  a  natural  sequence 


GENERAL  PRINCIPLES  OF  FIRST  AID  19 

to  these  requirements,  is  the  first  rule  of  procedure  in  the 
appHcation  of  first  aid:  Never  act  bhndly  witliout  a  good 
and  sufficient  reason  for  any  method  of  treatment  which 
you  may  adopt.  When  you  have  practised  first  aid  for  some 
time  you  will  realize  that  emergencies  which  will  not  per- 
mit a  short  period  for  examination  and  consideration  are 
extremely  rare,  and  that  hurried  conclusions,  made  during 
a  period  of  excitement,  are  more  apt  than  not  to  be  incor- 
rect. A  man  fell  from  a  scaffold  and  was  seen  at  once  by 
a  first-aid  enthusiast,  who  recognized  the  symptoms  of 
shock.  In  order  to  treat  the  shock  in  a  satisfactory  manner 
he  hurriedly  carried  the  man  into  a  neighboring  house  and 
put  him  to  bed,  entirely  overlooking  the  fact  that  his  patient 
had  a  badly  fractured  leg,  which,  during  the  trip  to  the 
house,  became  compounded,^  with  resulting  infection  of  the 
wound.  This  error  of  judgment  added  considerably  to  the 
suffering  of  the  patient  and  lengthened  his  period  of 
disability. 

The  nature,  extent  and  severity  of  the  injury  should  be 
determined  so  that  an  intelligent  message  may  be  sent 
to  the  physician.  If  a  physician  is  told  that  a  man  has  been 
injured  and  apparently  has  a  fracture  or  dislocation  of  the 
hip;  or  that  a  child  has  been  run  over  and  has  large  wounds 
of  the  head  and  arms,  he  will  have  some  idea  of  what  to 
bring  with  him,  and  the  result  will  be  that  considerable 
time  will  be  saved  in  the  end.  In  addition,  be  sure  that,  in 
sending  for  a  physician,  directions  are  given  so  that  he  may 
come  directly  to  the  given  location  without  difficulty.  If 
there  is  any  chance  for  a  mistake,  send  someone  to  meet  the 
physician,  if  possible.  I  have  been  called  to  an  emergency 
case  "on  Broadway"  by  an  excited  individual  who  neglected 
to  tell  me  on  what  part  of  Broadway,  and  to  "Brown's  Drug 
Store,"  by  someone  who  hung  up  the  receiver  before  I  could 
tell  him  that  I  had  never  heard  of  such  a  store.  In  the  coun- 
try it  is  not  uncommon  to  be  instructed  to  turn  do-^Ti 
"Jones's  Lane,"  when  the  physician  is  unacquainted  with 
the  locality  and  is  unable  to  distinguish  "Jones's  Lane," 

1  That  is,  the  sharp  end  of  the  broken  bone  was  forced  out  through  the 
skin,  adding  a  wound  to  the  other  injury. 


20  GENERAL  PRINCIPLES  OF  FIRST  AID 

from  tlio  many  other  lauos  wliicli  l)raiu'li  from  the  main  road. 
Ill  such  a  case  it  is  wise  to  send  someone  to  meet  the  physi- 
cian at  the  entrance  of  the  lane,  or  at  some  other  point 
easily  located. 

Find  out  all  you  eau  from  tlie  paticMit  and  the  witnesses 
regarding:;  the  accident.  While  you  are  doing  this  note  the 
condition  of  the  jnilse,  the  color  of  the  face  and  lips,  and  the 
state  of  consciousnei>s.  Then,  hearing  the  history  in  mind, 
make  a  careful  (>xamination  to  locate  wounds,  fractures,  etc. 
The  examination  should  he  thorough  and  should-  he  guided 
by  the  history  and  symptoms.  IIowcwm-,  a  ])artial  exami- 
nation Avill  often  indicate  the  extent  of  the  injury.  Thus 
when  a  patient  has  stejjped  off  the  curh  and  turned  his 
ankle,  and  is  found  sitting  comfortably  in  a  chair,  it  is 
hardly  necessary  to  examine  the  arms  for  fractures,  or  the 
head  for  scalp  wounds.  It  is  to  be  supposed  that  in  such  a 
case  the  patient  has  enough  intelligence  to  indicate  the 
location  of  the  injury.  In  other  cases,  where  a  man  has 
fallen  from  a  height  and  is  only  semiconscious,  almost  any 
conceivable  injury  may  have  occured,  and  the  head,  arms, 
legs,  and  back  should  be  carefully  examined. 

If  the  injury  is  apparently  severe  it  is  well  to  send  at  once 
for  blankets,  hot-water  l^ottles,  stimulants,  etc.  If  these  are 
later  found  to  be  unnecessary  it  has  done  no  harm  to  luu'e 
them  ready.  Often  the  injury  has  been  very  slight,  the 
patient  having  merely  fainted  from  fear,  recovery  occurring 
in  a  few  minutes  without  any  treatment  other  than  rest  in 
the  recumbent  position.  If  the  patient  is  in  an  uncomfort- 
able position  it  may  be  necessary  to  move  him  at  once  to  a 
place  where  he  can  be  more  conveniently  examined.  To  do 
this,  make  a  hurried  examination  to  detect  any  injury 
which  might  be  made  worse  by  transportation,  and  then 
move  him  the  shortest  ])ossible  distance  to  a  spot  where  a 
more  thorough  examination  may  be  made. 

If  there  is  a  wound,  rip  or  cut  the  clothing  away  so  that 
the  injury  may  be  plainly  seen.  Do  not  attempt  to  apply  a 
tournif{uet  to  stop  hemorrhage  before  you  have  seen  the 
bleeding-point.  A  case  has  recently  occurred  where  a  man 
bled  to  death  from  a  ruptured  varicose  vein  because  no  one 


GENERAL  PRINCIPLES  OF  FIRST  AID 


21 


had  the  intelligence  to  cut  open  the  clothing  and  apply 
pressure  with  one  finger  against  the  bleeding-point.  The 
man  had  been  given  a  stimulant  and  had  had  a  bandage 
wrapped  about  the  bleeding  leg,  but  no  one  had  sufficient 
training  in  first  aid  to  look  for 
the  bleeding-point  and  stop  the 
hemorrhage  by  direct  pressure. 

If  you  do  not  know  what  to 
do,  do  nothing  at  all.  It  is 
never  necessary  to  act  for  the 
mere  sake  of  doing  something. 
In  the  case  mentioned  above, 
if  one  of  the  bystanders  had 
not  secured  a  sheet  and  wrapped 
it  about  the  leg,  thus  hiding 
the  extent  of  the  hemorrhage 
it  is  possible  that  someone 
else  might  have  examined  the 
leg  and  noticed  that  the  blood 
came  from  one  small  point, 
and  could  easily  be  stopped 
by  pressure. 

Above  all,  remember  that 
first  aid  is  only  common-sense 
combined  with  a  little  scien- 
tific knowledge.  When  you 
first  see  a  patient,  keep  cool 
and  do  the  obvious  thing,  such 
as  putting  out  the  fire  in  burn- 
ing clothing,  pulling  a  person 
out  from  under  the  horses' 
hoofs,  getting  him  away  from 

falling  timbers,  rescuing  a  drowning  person,  and  other  simi- 
lar actions.  Then  proceed  with  the  examination  and  do 
the  thing  which  your  knowledge  of  first  aid  teaches  you  is 
right  and  proper.  But  be  sure  to  keep  cool,  and  know  what 
you  are  doing,  and  why. 

The    United  States  Manual  gives  the  following  general 
first-aid  rules  for  the  sanitary  troops: 


Fig.  1. — Varicose  veins  of  leg. 
A  small  wound  of  these  veins 
bleeds  profusely.     (Park.) 


22  ,    GENERAL   PRIXCIPLES  OF  FIRST  AID 

1.  Act  quickly  and  quietly. 

2.  Make  the  jjatient  sit  or  lie  down. 

3.  See  the  injury  clearly  before  you  treat  it. 

4.  Do  not  remove  more  clothing  than  is  necessary  to 
examine  the  injury,  and  keep  the  patient  warm  with  cover- 
ing if  needed.  Always  rip,  or  if  you  cannot  rip,  cut  the 
clothing  from  the  injured  part,  and  pull  nothing  off. 

").  (live  alcoholic  stinnilants  slowly  and  cautiously,  and 
only  when  necessary.  Hot  drinks,  when  obtainable,  will 
often  suffice. 

().  Keep  from  the  ])atient  all  persons  not  actually  needed 
to  help  him. 

EQUIPMENT    AND    SUPPLIES. 

The  equipment  and  supplies  needed  by  the  first-aid 
worker  vary  within  wide  limits.  The  further  the  student 
progresses  in  first-aid  experience,  the  better  he  is  able,  in  an 
emergency,  to  secure  satisfactory  results  with  whatever 
supplies  he  may  find  at  hand.  In  some  cases  he  may  be 
limited  to  those  supplies  which  may  be  secured  at  an  instant's 
notice;  in  others,  he  may  have  available  all  the  surgical 
supplies  of  a  well-equipped  hospital.  In  general,  it  is  better 
to  use  the  specially  prepared  supplies  when  they  are  to  be 
obtained,  but  the  intelligent  worker  will  often  be  able  to 
improvise  material  and  supplies  with  which  he  can  attain 
most  creditable  results. 

Thus,  it  is  possible  to  obtain  a  sterile  dressing  by  boiling 
a  piece  of  linen  or  gauze  or  by  dipping  a  clean  hanilkerchief 
in  alcohol.  Personally,  I  have  had  excellent  results,  when 
sterile  supplies  were  not  available,  by  applying  a  clean  hand- 
kerchief wet  with  cologne  (or  whisky)  directly  against  a 
bleeding  surface,  and  bandaging  it  firmly  against  the  wound. 

On  one  occasion  a  hospital  orderly,  while  in  bathing, 
accidentally  cut  a  large  vein  in  his  leg,  which  bled  profusely. 
He  was  near  the  shore,  but  a  considerable  distance  from  his 
party.  There  was  literally  nothing  but  sea  and  sand  at 
hand.  The  man  had  had  enough  experience  to  know  that 
he  was  in  danger  from  the  profuse  hemorrhage,  so  he  sat 
upon  the  beach  and  placed  both  thumbs  in  the  wound, 
eft'ectually  stopping  the  hemorrhage.    Twenty  minutes  later 


EQUIPMENT  AND  SUPPLIES  23 

his  friends  found  him  and  apphed  a  permanent  dressing. 
It  may  be  added  that  although  he  did  not  receive  medical 
treatment  for  several  hours,  the  wound  did  not  become 
infected.  This  was  because  the  wound  and  hands  had  been 
well  cleansed  with  sea  water,  which  contains  few  pus-forming 
bacteria. 

Although  it  is  sometimes  necessary  to  work  with  impro- 
vised tools,  better  results  will  be  obtained  if  the  proper  sup- 
plies are  at  hand.  Numerous  first-aid  kits  have  been  advised, 
but  they  must,  necessarily,  vary  considerably,  the  contents 
depending  largely  upon  the  purpose  to  which  the  packet  is 
to  be  put.  In  the  choice  of  a  first-aid  kit  the  following  points 
must  be  taken  into  consideration : 

1.  The  size  and  weight. 

2.  Character  of  injuries  likely  to  occur. 

3.  The  experience  of  the  operator. 

The  size  and  weight  are  of  the  utmost  importance.  It  is 
at  once  apparent  that  a  complete  equipment,  such  as  might 
be  ideal  for  a  theater  or  factory,  would  prove  much  too 
large  and  heavy  to  carry  on  a  canoe  trip,  while  the  kit  car- 
ried in  the  canoe  would  be  too  large  and  heavy  to  carry  on 
a  tramp  through  the  woods.  If  size  or  weight  does  not 
need  to  be  considered,  much  more  latitude  may  be  given  in 
the  choice  of  supplies. 

The  character  of  the  prevalent  injuries  in  a  given  locality 
must  also  be  taken  into  consideration.  In  certain  factories 
burns  are  very  common,  so  that  extra  preparation  should 
be  made  for  this  injury.  In  others,  small  particles  are  apt 
to  get  into  the  eyes  and  provision  must  be  made  for  their 
removal.  On  fishing  trips  the  fish-hooks  are  apt  to  be  stuck 
in  the  hands.  I  have  known  fishermen  who  carried  a  sharp 
pair  of  wire  cutters  when  they  were  on  long  trips.  If  the 
hook  is  stuck  too  deeply  into  the  hand  to  be  withdrawn  the 
point  is  pushed  inward  until  the  curve  causes  it  to  emerge 
from  the  skin.  The  barbed  point  is  then  cut  away  and  the 
hook  is  easily  withdrawn. 

The  skill  of  the  operator  should  also  be  taken  into  consid- 
eration. If  the  first-aid  worker  has  had  no  experience  in 
the  use  of  siu-gical  instruments,  it  is  unnecessary  to  include 
them  in  the  outfit.    In  some  cases,  as  on  sea  voyages  and 


24  GENERAL  PRINCIPLES  OF  FIRST   AID 

loiiij  tri])s  into  tlie  woods,  it  is  advisable  to  carry  suture 
materials  and  simple  surs^ical  instruments,  so  that  they  may 
be  used  when  requiretl. 

Probably  the  simjilest  form  of  first-aid  packet  is  that  used 
by  the  soldier.  This  must  be  small,  lifj;ht,  and  easily  a])i)lied. 
Each  soldier  in  the  T'nited  States  Army  carries  an  indi- 
vidual sealed  first-aid  packet  which  is  for  his  own  personal 
use. 

Contents  of  United  States  Annij  First-aid  Packet. 

Printed  slip  of  directions 1 

Gauze  bandages  4  X  84  inches 2 

Gauze  compresses,  one  sewed  to  each  liandage  .  2 

Safety-pins 2 

In  the  army  packet  the  gauze  is  sewn  to  the  bandage  so 
that  it  may  be  applied  to  the  wound  without  being  handled. 
The  gauze  and  bandages  are  both  hnpregnated  with  a  solu- 
tion of  bicliloride  of  merciu-y. 

The  Hospital  Corps  of  the  Army,  that  is,  the  enlisted  ])er- 
sonnel  of  the  sanitary  troops,  carry  a  first-aid  ])ouch  which  is 
much  more  complete  and  which  is  for  the  use  of  the  members 
of  the  Hospital  Corps  in  applying  first  aid  before  the  injured 
soldier  is  seen  by  the  surgeon. 

United  States  Army  Ilusintal  Corps  First-aid  Pouch. 

Compressed  gauze  bandages G 

Gauze  compresses  (5  yard) 4 

Iudi\'iduai  first-aid  packets,  ns  ub')vc 10 

Iodine  swabs 1  dozen 

Common  pins }  paper 

Safety-pins .  1  dozen 

Adhesive  plaster,  5  yards  by  1  inch         1  spool 

Aromatic  spirits  of  ammonia 1  flask 

Cup 1 

Tournicjuct,  field 1 

Dressing  forceps 1 

Scissors 1 

Lead-pencil 1 

Diagnosis  tags 1  book 

The  purpose  of  this  packet  is  to  supply  the  necessary 
efjuipment  for  first  aid  such  as  is  commonly  retpiired  on  the 
field  and,  at  the  same  time,  not  to  overload  the  attendant 
with  seldom-needed  sui)})lies. 


THE  ORGANIZATION  OF  FIRST  AID  25 

For  household  use  considerable  latitude  may  be  allowed 
in  the  selection  of  supplies.  The  following  has  been  suggested 
as  inexpensive,  and  at  the  same  time  fulfilling  all  ordinary 
requirements : 

HouseJiold  First-aid  Outfit. 

Bandages,  assorted  sizes  3 

Sterile  gauze 1  yard 

Cotton J  pound 

Tincture  of  iodine  (one-half  strength) 1  ounce 

Carron  oil,  for  burns 4  ounces 

Aromatic  spirits  of  ammonia 1  ounce 

Adhesive  plaster  (1  inch  by  5  yards) 1  roll 

Clinical  thermometer 1 

Safety-pins 1  dozen 

Vaseline 1  bottle 

Boric  acid  (powdered) 2  ounces 

In  a  household  set  of  this  sort  almost  any  of  the  household 
remedies  may  be  added,  such  as  castor  oil,  Epsom  salts, 
soda-mint  tablets,  alcohol,  witch-hazel,  hot-water  bag,  ice- 
cap, syringe,  etc.  It  is  advisable  to  prepare  such  an  outfit 
as  the  above  and  keep  it  always  complete  and  available  for 
emergency  use. 

Numerous  first-aid  kits  have  been  prepared  by  the  surgi- 
cal supply  houses.  Burrows,  Wellcome  &  Co.  prepare  small 
cases  which  are  made  very  compact  by  the  use  of  com- 
pressed cotton  and  gauze,  and  medicine  put  up  in  collapsible 
tubes.  A  simple  one  called  the  "Boy  Scout's  First-aid  Case" 
contains  aromatic  spirits  of  ammonia,  boric  acid  ointment, 
carron  oil,  bandages,  dressings,  collodion,  pins,  and  adhesive 
plaster.  Larger  and  more  complete  sets  may  be  secured 
from  dealers. 

It  is  desirable  that  any  outfit  for  general  use  should  be 
made  as  simple  as  possible,  so  that  it  may  be  used,  and 
used  correctly,  by  M^hoever  happens  to  be  present  when  the 
emergency  arises.  When  special  training  is  given  to  attend- 
ants who  are  constantly  present,  as  in  factories,  shipyards, 
and  the  like,  the  more  complete  outfits  are  to  be  preferred. 

THE    ORGANIZATION    OF   FIRST    AID. 

In  the  development  of  first  aid  in  schools,  colleges,  and  in 
industrial  organizations  the  formation  of  first-aid  squads 


20         .     CEXERAL   PRIXCfPLES  OF  FIRST   AID 

lias  recently  been  advised  and,  in  some  locations,  most  care- 
fully carried  out.  The  systematic  study  of  emerfiency 
treatment,  together  with  the  feelin.u-  wliic-h  each  member  of 
the  scpiad  has  that  he  is  takiiiij  an  active  i)art  in  first-aid 
work  and  not  merelv  stmhin"-  the  suhiect  in  the  abstract, 
has  given  a  decided  stimulus  to  the  entire  subject.  In  addi- 
tion, the  increasing  interest  in  first  aid  has  led  to  interest 
in  sanitation  and  personal  hygiene,  with  consequent  improve- 
ment in  health. 

In  practice,  four  men  usually  constitute  a  "first-aid 
squad."  One  man  is  appointed  captain  and  the  other  three 
assistant  workers.  They  study  the  general  problems  of 
first  aid,  and  at  the  same  time  the  particular  i)r<)blems  of 
the  school  or  factory  in  M'hich  they  work.  They  also  study 
"team  work,"  two  of  the  assistants  carrying  the  stretcher 
and  the  third  carrying  the  first-aid  packet.  Each  man  knows 
his  place  and  takes  it  without  special  instruction.  In  addi- 
tion, each  man  is  trained  to  occupy  the  position  of  captain, 
or  any  other  position  which  may  become  vacant. 

In  order  to  stimulate  interest  and  competition,  certain 
companies  have  had  first-aid  meets,  into  which  the  first-aid 
squad  enter  with  all  the  zest  of  a  college  student  at  an  athletic 
meet.  Problems  in  first  aid  are  given  and  ])rizes  given 
to  the  squad  whose  performance  is  nearest  perfect,  the  mark- 
ing being  done  on  the  basis  of  speed,  skill,  and  judgment. 
After  a  little  practice,  and  with  a  groundwork  of  the  prin- 
ciples of  first  aid,  it  is  remarkable  how  skilfully  uneducated 
workers  will  tackle  original  problems  in  first  aid;  for  example, 
the  removal  of  a  patient  with  a  fractured  leg  from  a  deep 
exca\-ation  or  the  carrying  of  an  unconscious  man  from  the 
roof  of  a  high  building. 

This  phase  of  the  subject,  which  has  been  largely  neg- 
lected except  in  the  army  and  the  navy,  deserves  a  more 
prominent  place  in  civil  life.  The  institution  of  the  study 
of  first  aifl  and  the  development  of  the  practice  of  first  aid 
by  the  formation  of  first-aid  squads  is  earnestly  recom- 
mended for  schools,  stores,  factories,  and  elsewhere,  where 
large  groups  of  indi\iduals  are  brought  together. 


CHAPTER   II. 

ANATOMY  AND  PHYSIOLOGY. 

For  a  proper  understanding  of  the  principles  of  first  aid 
it  is  necessary  to  have  some  knowledge  of  the  elements  of 
normal  anatomy  and  physiology.  The  better  the  normal 
workings  of  the  body  are  understood,  the  easier  it  will  be  to 
apply  the  appropriate  treatment  for  a  given  injury. 

THE   BONES. 

In  ordinary  first-aid  work  only  a  general  working  knowl- 
edge of  anatomy  is  required.  For  purposes  of  description 
it  is  necessary  to  designate  the  various  bones  by  special 
names,  but  it  is  only  required  that  the  student  have  a  general 
understanding  of  their  size  and  location,  without  attempting 
to  learn  their  anatomical  names. 

The  Skeleton. — The  bony  framework  of  the  body,  taken 
as  a  whole,  is  known  as  the  skeleton.  The  bones  serve 
to  give  attachment  to  the  muscles  and  act  as  a  support  for 
the  body  and  as  an  aid  to  locomotion.  They  also  serve  to 
protect  the  delicate  organs  from  external  injury.  Thus,  the 
brain  is  protected  by  the  skull  and  the  heart  and  lungs  by 
the  ribs.  They  also  serve  as  an  aid  and  support  for  most  of 
the  voluntary  actions.  For  instance,  if  the  hands  and  arms 
contained  no  bones  all  of  the  ordinary  movements  would  be 
difficult  or  impossible.  On  the  other  hand,  most  of  the  invol- 
untary movements  of  the  body,  such  as  the  heart  action  and 
the  digestion,  go  on  without  the  direct  aid  of  the  skeleton. 

The  skeleton  is  divided,  for  purposes  of  description,  into 
the  head,  the  trunk  and  the  extremities. 

The  Head. — The  head  is  made  up  of  the  cranium  and 
the  bones  of  the  face.     The  craniimi  is  a  firm  bony  case 


■28 


ANATOMY  AND   PllYSlOLOay 


Fig.  2. — Front  view  of  the  adult  skeleton:  1,  frontal  bone;  2,  parietal  bone; 
3,  nasal  bones;  Jf,  occipital  bone;  5,  orbit;  6,  malar  bone;  7,  7,  upper  and  lower 
maxillm;  8,  nasal  cavity;  9,  cervical  vertebra;;  10,  clavicle;  11,  scapula;  12, 
sternum;  13,  ribs;  IJf,  IJt,  dorsal  and  lumbar  vertebra;;  15,  15,  innominate 
bones:  16,  sacrum;  17,  humerus;  18,  radius;  19,  ulna;  20,  carpus;  21,  meta- 
carpus; 22,  phalanges  of  hand;  23,  femur;  S-|,  patella;  25,  fibula;  26,  tibia; 
27,  OS  calcis  and  astragalus;  28,  cuneiform  and  ciiljoid  bones;  29,  metatarsus; 
30,  phalanges  of  toes. 


THE   HONES 


29 


which  protects  the  l)raiu.  It  consists  oF  several  Hatteiicfl 
bones,  forming'  when  nnited  a  strong  i)rotective  covering, 
completely  enclosing  the  delicate  tissues  of  the  brain.    The 


o 


walls  of  the  skull  are  about  one-eighth  to  one-fourth  of  an 
inch  in  thickness.  In  children  they  are  ^'ery  much  thinner, 
indeed,  in  young  infants,  there  are  certain  locations  on  top 


30 


AXATOMY  A\n  PiiYsmLnaY 


of  the  head  wIutc  tlie  skull  is  very  thin  and  nienil)ran()us  in 
character,  luning  not  yet  inidergone  bony  change. 

In  the  anterior  portion  of  the  head  is  the  face,  formed  by 
several  small  bones  which  together  act  as  a  b()n\'  framework 
for  the  nose,  cheeks,  and  jaws,  while  the  forehead,  on  the 
other  hand,  is  formed  by  a  portion  of  the  skull.  It  is  impor- 
tant to  remember  this  relation  because,  in  injuries  to  the 
forehead,  we  may  expect  an  associated  fracture  of  the  skull 


Fig.  4. — Side  %'iew  of  the  lower  Jaw.     (Gray.) 


and  an  injury  to  the  brain,  while  in  injuries  to  the  portion 
of  the  face  below  the  eyes,  coincident  brain  injury  is 
uncommon. 

The  upper  teeth  are  located  in  the  maxilla,  or  upper  jaw, 
and  the  lower  teeth  in  the  mandible,  or  lower  jaw. 

The  Mandible. — This  bone,  sometimes  called  the  inferior 
maxilla,  sometimes  referred  to  simply  as  the  jaw  bone,  is 
the  only  bone  of  the  face  which  is  movable.  It  moves  freely 
on  two  joints  which  are  situated  in  the  skull  just  in  front  of 


THE  BONES 


31 


the  ears,  and  its  motion  is  lim- 
ited chiefly  to  an  up-and-down 
hinge-hke  action. 

The  Trunk.—The  trunk  con- 
sists of  the  spinal  cohmin,  the 
ribs,  and  the  pelvis. 

The  Spinal  Column.  —  The 
spinal  column  extends  from  the 
skull  to  the  pelvis,  and  serves 
as  the  bony  framework  of  the 
neck  and  as  the  main  support  of 
the  chest  and  abdomen.  It  is 
formed  by  twenty-four  irregu- 
larly shaped  disk-like  bones 
(vertebrae),  which  are  very 
strong-,  and  serve  for  the  attach- 
ment of  the  strong  muscles  of  the 
back  and  as  a  protection  for  the 
spinal  cord,  which  runs  through 
a  canal  formed  by  the  openings 
in  the  center  of  the  disk-like 
bones,  the  spinal  canal.  The 
bones  of  the  spine  may  be  felt 
in  the  middle  of  the  back,  run- 
ning from  the  skull  to  the 
pelvis. 

The  Ribs.  —  These  are  flat 
ribbon-shaped  bones,  twelve  on 
each  side,  curving  from  the 
spine  to  the  breast  bone  in  front. 
They  enclose  the  heart  and 
the  lungs  in  the  cavity  of  the 
chest.  They  are  thin  bones,  and 
comparatively  easily  broken, 
moving  slightly  with  respi- 
ration. 

The  Pelvis. — At  the  lower  end 
of    the   spine   is   a  firm   bony 

Fig.  5. — Lateral  view  of  vertebral 
column.     (Gray.) 


Jul  cervical 
or  Alius. 


32      ,  AX  ATOMY   AM)   PIIYSIOIAKIY 

case  which  contains  the  bhithler,  the  rectum,  and  the  organs 
of  generation.  This  is  the  pelvis,  and  is  formed  of  large 
heavy  bones,  which,  besides  serving  as  a  protection  for  the 
contained  organs,  must  bear  the  weight  of  the  body.  The 
pelvis  is  larger  above  than  belo^\',  the  flaring  upper  edge 
being  felt  at  the  sides  just  below  the  waist  line.  Two  strong 
processes  which  project  downward  serve  to  support  the 
body  while  sitting,  while  on  the  outer  side  of  the  pelvis  are 
two  large  joint  ca\itics  which  articulate  with  the  large  bones 


Fig.  6. — Bony  pelvis  from  above.     (Gray.) 


of  the  thighs.  In  the  back  the  pelvis  is  formed  by  a  thick 
wedge-shaped  bone,  the  sacrum,  which  bears  the  direct 
weight  of  the  body  transmitted  through  the  spine. 

The  Upper  Extremity. — The  upper  extremity  consists  of 
the  cla\icle,  the  scapula,  the  humerus,  the  radius,  the  ulna, 
and  the  small  bones  of  the  wrist  and  hand.     (Fig.  2.) 

The  Clavicle. — The  cLaA'icle,  or  collar  bone,  is  the  bone  that 
can  be  felt,  as  a  cylmdrical  curved  bone,  at  the  front  of  the 
base  of  the  neck.     It  extends  from  the  upper  part  of  the 


THE  BONES  33 

sternum,  or  breast  bone,  at  its  inner  end,  to  the  shoulder- 
blade,  externally.    This  bone  is  frequently  fractured. 

The  Scapula. — This  is  commonly  called  the  shouhler-blade, 
and  is  the  thin  flat  triangularly  shaped  bone  that  can  be 
felt  just  back  of  the  shoulder.  When  the  shoulders  are 
drawn  back  the  scapulae  form  wing-like  projections,  which 
are  plainly  evident  in  thin  persons.  At  the  outer  angle  is  a 
hollow  cavity  which  forms  the  shoulder-joint  with  the  head 
of  the  large  bone  of  the  upper  arm. 

The  Humerus. — This  is  the  largest  bone  in  the  upper 
extremity,  and  is  sometimes  spoken  of  as  the  arm  bone.  It 
joins  above  with  the  shoulder-blade  and  below  with  the 
bones  of  the  forearm.  In  adults  this  bone  is  usually  an 
inch  or  more  in  diameter.    It  is  frequently  fractured. 

The  Forearm. — ^There  are  two  bones  in  the  forearm,  the 
radius  and  the  ulna.  The  radius  is  the  heavier  bone,  and  is 
located  on  the  thumb  side  of  the  forearm.  The  ulna  is  a 
little  longer  than  the  radius  and  is  the  bone  that  forms  the 
point  of  the  elbow.  It  can  be  plainly  felt  just  beneath  the 
skin  extending  from  the  point  of  the  elbow  down  to  the 
inner  side  of  the  T^Tist.  At  the  wrist  the  radius  is  on  the 
thumb  side,  while  the  lower  end  of  the  ulna  can  be  felt  as  a 
rounded  prominence  on  the  back  of  the  ^^Tist  on  the  same 
side  as  the  little  finger.  Both  of  these  bones  are  frequently 
fractured. 

The  Carpus. — ^There  are  eight  small  bones  in  the  hand 
which  are  crowded  together  in  what  is  commonly  called  the 
wrist.  Because  they  are  so  small  and  so  crowded  together 
it  is  very  difficult  to  locate  a  fracture  or  dislocation  of 
these  bones  with  any  degree  of  certainty. 

The  Metacarpus. — There  are  five  elongated  bones,  one  for 
each  digit,  called  metacarpal  bones.  In  general,  they  occupy 
the  location  of  what  is  commonly  called  the  palm  of  the  hand. 

The  Phalanges. — ^Two  shorter  bones,  similar  in  shape  to 
the  metacarpals,  go  to  make  up  the  thumb.  They  are  called 
the  phalanges.  The  one  nearest  the  hand  is  designated  as 
the  proximal  phalanx,  and  the  one  forming  the  tip  of  the 
thumb  is  called  the  terminal,  or  distal  phalanx.  In  the  fin- 
gers are  found  analogous  bones,  except  that  there  are  three 
3 


34 


AX  ATOMY  AXD   PIIYSTOLOaY 


phalanges  in  each  fiiijjcr.  The  phalanges  of  the  fingers  are 
sonietinies  ealled  the  first,  the  second,  and  thiixl  phalanges 
of  the  respective  fingers,  the  first  being  the  one  nearest  the 
hand.  The  metacarpal  liones  and  the  i)halanges  are  fre- 
quently injured,  both  fracture  and  dislocation  being  very 
common. 


Scaphoid  ■.,,^ 
Os  magnum  - . 
Trapfziu/n ..... 
Trapezoid  -..._ 

Netacffrpal  /)o>ies_ 


Semilunar 

-Cuneiform 

F/siform 
l/nciform 


fManxM- 


FiG.  7. — Showing  detail  of  the  bones  of  the  hand. 

The  Lower  Extremity. — The  lower  extremity  consists  of 
the  femur,  the  patella,  the  tibia,  the  fibula,  and  the  small 
bones  of  the  ankle  and  the  foot. 


THE  BONES 


35 


The  Femur. — The  large  thigh  hone  is  known  as  the  femur. 
It  is  the  largest  and  strongest  hone  in  the  hody,  and  extends 
from  the  pelvis  to  the  knee.  The  thigh,  like  the  arm,  con- 
tains only  one  bone. 


P/iaia/ixJT. 


P/ialc/uxI... 


Netutfosai  dones 

Jnt.c/juftfo/v/i.  .. 
Nid.  ciadeforui 
Ext.  c/iniefor/u .... 

Kavlcalar  l/oue. . 
Astragalus 


7//berosit>j  of  fifth 
7// eta  tarsal  Ao/ie. 


Culfoid  dom 


Os  Calcis 


Fig.  8. — Bones  of  the  right  foot. 


The  Patella. — A  small  rounded  bone,  about  the  size  of  a 
silver  dollar,  forms  the  prominence  of  the  knee.    It  is  kno\\Ti 


31)  .  ANATOMY  AND  PHYSIOLOGY 

as  the  patella,  or  knee-cap.  It  serves  as  an  aid  to  the  iimseiilar 
action  of  the  knee-joint.  It  can  be  easily  felt  beneath  the 
skin.     It  is  freqnently  fractured. 

The  Leg. — The  bones  of  the  leg  correspond  to  those  of  the 
forearm.  There  is  a  large  strong  bone,  the  tibia,  and  a  long 
slender  bone,  the  fibula.  The  tibia  is  called  the  shin  bone, 
and  can  be  felt  beneath  the  skin  along  the  shin  and  at  the 
inner  side  of  the  ankle-joint.  The  fibula  is  deeply  situated 
in  the  muscles  of  the  calf,  and  can  be  felt  only  at  the  upper 
end,  on  the  outer  side  of  the  leg,  just  below  the  knee-joint, 
and  on  the  lower  end  where  it  lies  on  the  outer  side  of  the 
ankle-joint. 

The  Tarsus. — There  are  seven  small  irregularly  shaped 
bones  of  the  foot  which  correspond  roughly  to  the  bones  of 
the  carpus.  In  the  foot  one  of  these  bones,  the  os  calcis,  is 
especially  well  developed,  forming  the  heel. 

The  Metatarsus. — This  corresponds  to  the  metacarpus  in 
the  hand.  The  metacarpal  bones  occupy  that  portion  of 
the  foot  between  the  midpoint  of  the  foot  and  the  base  of 
the  toes.     They  are  five  in  number. 

The  Phalanges. — ^The  phalanges  of  the  foot  are  analogous 
to  those  of  the  hand,  but  are  smaller  and  less  well  developed. 

Fractures  of  the  lower  extremity  are  less  common  than 
those  of  the  upper  extremity  but  the}'  are  sufficiently  com- 
mon to  be  of  considerable  interest  to  the  first-aid  worker. 

THE   JOINTS. 

The  bones  are  joined  together  by  strong  fibrous  bands 
called  ligaments.  Where  the  bones  move  on  each  other 
there  is  formed  a  joint  or  articulation.  In  some  cases  the 
bones  are  joined  so  firmly  that  there  is  no  motion,  as  in 
the  bones  of  the  skull  and  in  the  pelvis.  In  other  cases  there 
is  only  slight  motion,  as  in  the  spine  and  the  ribs,  A\'hile  in 
other  joints  the  motion  is  very  free,  as  in  the  shoulder  and 
in  the  hip.  Where  motion  is  possible  in  all  directions  the 
joint  is  known  as  a  ball-and-socket  joint.  In  other  cases 
motion  is  possible  in  only  one  plane,  such  as  at  the  elbow 
and  the  knee-joint.    Such  a  joint  is  known  as  a  hinge-joint. 


THE  JOINTS 


37 


Many  of  the  joints  are  technically  regarded  as  hinge-joints, 
although  they  have  a  small  amount  of  lateral  motion. 


Oblique  'popliteal 
ligament 


Medial  menibcus 


Adipose  tissue 


Bursa  under  Quadriceps 
feinoris 


Infja    III 
^patellar  , 

^ —  Medial  meniscus 

y 

*y  ~L  (jamenium  paiellce 

Iiu)sa  between  tibia  and 
ligamentu77i  patellae 


Fig.  9. — Longitudinal  section  of  the  knee-joint  showing  ligaments,  joint 
cavity  and  knee-cap,     (Gray.) 


?s 


ANA  TOM  Y  A ND   PH YSIOLOGY 


Each  joint  is  lined  with  a  thin  membrane  called  synovial 
membrane,  which  secre  es  a  scrons  finid.  The  jinrpose  of 
this  Hnid  is  to  act  as  a  hibricant  for  the  movement  of  the 
joint.  When  the  synovial  membrane  l)t>c()mes  inflamed  the 
the  condition  is  known  as  svnovitis. 


Ani.  inf.  iliac  spine -. 


Intertrochanteric 
line 


Fig.  10. — Right  hip-joint  from  the  front  with  muscles  entirely  removed, 
showing  the  strong  capsule  thickened  in  front  to  form  the  iliofemoral 
ligament.     (Gray.) 

The  ligaments  are  strong,  fibrous  bands  passing  across  the 
joint,  and,  being  attached  to  the  bones  on  either  side  of  the 
joint,  serve  as  restricting  bands.     In  some  joints  they  are 


THE  JOINTS 


39 


fL£X   lONC  POl 


Fig.  11. — Sole  of  the  foot  with  muscles  removed,  showing  strong  liga- 
ments which  hold  the  bones  together  and  support  the  arch  of  the  foot. 
(Allen.) 


40        .  ANATOMY  AXD   rilYSIOLOGY 

very  firm,  allowing  little  or  no  movement,  while  in  other 
locations  they  must  be  \evy  lax  to  allow  the  joint  to  move 
freely.  If  you  attempt  to  bend  the  terminal  phalanx  of  the 
finger  to  the  side  it  is  found  to  be  firmly  jield  in  place.  That  is 
because  the  lateral  ligaments  are  com})arati\'ely  short  and 
strong.  When  the  same  phalanx  is  moved  in  the  other  direc- 
tion the  movement  is  fairly  free,  being  limited  only  by 
extreme  flexion  or  extension.  Consecpiently  it  is  apparent 
that  the  ligaments  on  the  front  and  back  of  the  phalanges 
must  be  long  and  lax. 

In  some  joints,  such  as  the  small  joints  of  the  ankle,  all 
the  ligaments  are  short  and  strong,  so  as  to  gi\'e  a  firm  sup- 
port and  allow  very  little  movement,  while  in  other  joints, 
for  example  the  shoulder,  free  movement  in  all  directions 
is  permitted  by  the  fact  that  all  the  ligaments  are  long  and 
lax.  In  the  shoulder  most  of  the  support  is  obtained  by  the 
strong  muscles  which  pass  across  the  joint  rather  than  by 
the  ligaments  which  offer  almost  no  supi)ort  to  the  ordinary 
joint  movements. 

When  the  joint  is  bent  so  as  to  decrease  the  angle  between 
the  bones  the  movement  is  known  as  flexion,  and  the  joint 
is  said  to  be  flexed.  Movement  in  the  opposite  direction  is 
extension  of  the  joint. 

When  the  movement  of  the  joint  is  such  as  to  carry  a 
portion  of  the  body  away  from  the  midline  the  movement 
is  known  as  abduction,  while  the  opposite  mo\'ement 
is  adduction. 

THE   MUSCLES. 

The  bones  are  controlled  by  muscles  which  constitute  the 
flesh  of  the  body.  Each  muscle  is  made  up  of  a  fleshy  por- 
tion, consisting  of  contractile  muscle  hirers,  on  either  end 
of  which  is  a  fibrous  tissue  band  known  as  the  tendon. 
Tendons  may  be  short  and  broad  or  may  be  long  narrow 
bands  several  inches  in  length.  The  ends  of  the  tendons  are 
attached  to  the  bones  and  are  usually  so  arranged  that  they 
pass  over  a  joint.  As  it  is  possible  to  contract  the  muscle 
at  will,  it  can  be  seen  that  the  contraction  of  the  muscle 
will  cause  voluntary  movement  of  the  corresponding  joint. 


THE  MUSCLES 


41 


In  the  human  body  the  processes  are  so  complex  that  even  the 
simplest  movements  are  usually  the  result  of  the  coordinated 


Fig.  12. — Muscles  of  the  shoulders,  neck  and  back.     On  the  right  side 
the  outer  layer  of  muscles  has  been  removed.     (Graj-.) 


42 


ANATOMY  AND   PHYSIOLOGY 


action  of  several  muscles.  A  rough  idea  of  the  number  and 
variety  of  the  nniselos  of  the  body  may  be  obtained  from  the 
ilhistrations  (l''ii2:s.  12  and  lo),  which  show  only  a  i>art  of 
the  nuiscles  of  the  back  and  arm. 


Fig.  13. — Superficial  muscles  of  left  side  of  chest  and  upper  arm.     (Gray.) 


In  some  cases  the  long  tendon  attached  to  a  muscle  allows 
it  to  act  on  a  bone  some  distance  from  the  body  of  the 


THE  BLOOD  AND  CIRCULATION  43 

muscle.  For  example,  the  fingers  are  bent  by  a  muscle  of 
the  forearm  which  acts  by  means  of  four  long  tendons, 
which  extend  from  above  the  wrist  to  the  distal  phalanx  of 
the  fingers.  The  tendinous  portion  of  the  muscle  has  no 
contractile  properties;  it  acts  merely  as  a  band  which  trans- 
mits the  pull  from  the  muscle  to  the  bone. 

As  muscles  act  only  by  contraction,  it  follows  that  they 
can  do  work  only  through  their  pulling  action.  Thus  one 
group  of  muscles  flexes  a  joint  while  another  group  extends 
it.  These  two  groups  are  said  to  oppose  each  other.  Where 
one  group  of  muscles  is  in  action,  the  opposing  group  is 
relaxed. 

The  muscles  surround  the  bones  throughout  the  greater 
part  of  the  body,  and,  in  turn,  are  covered  by  the  superficial 
fat  and  skin,  giving  form  to  the  body.  The  tendons  may  be 
deeply  located,  surrounded  by  muscles  and  fat,  or  they  may 
be  close  to  the  skin.  On  the  back  of  the  hand  the  tendons 
which  extend  the  fingers  are  very  superficial.  They  may  be 
easily  felt  moving  beneath  the  skin  when  the  fingers  are 
extended. 

The  muscles  described  above  are  called  voluntary  muscles 
because  they  are  under  the  control  of  the  will.  In  addi- 
tion to  these  there  is  in  the  body  another  type,  involun- 
tary muscles,  which  act  independently,  and  are  not  subject 
to  control.  Involuntary  muscles  are  found  in  the  heart,  the 
stomach,  the  intestines  and  in  other  internal  organs. 

They  are  of  the  utmost  importance  in  the  vital  functions 
of  the  body,  but  take  no  part  in  locomotion,  or  other  volun- 
tary movements.  They  exist  in  a  diffuse  layer  in  the  walls 
of  the  contractile  organs  but  differ  from  voluntary  muscles 
in  not  being  grouped  into  bundles  forming  distinct  muscles 
and  in  having  no  tendinous  attachments. 

THE   BLOOD    AND   CIRCULATION. 

The  Blood. — The  blood  is  a  fluid  tissue  which  circulates 
through  the  bloodvessels,  permeating,  by  means  of  the 
smaller  capillaries,  all  parts  of  the  body.  Its  chief  function 
is  to  carry  oxygen  and  nourishment  to  the  cells  of  the  entire 


44 


ANATOMY  AND  PHYSIOLOGY 


body  and  to  renioN^e  the  carbon  dioxide  and  other  waste 
products  which  result  from  ceUuUir  acti\'ity. 

It  is  composed  of  a  clear  straw-colored  fluid,  the  plasma, 
in  which  float  numerous  small  red  cells  that  gi\'e  to  the  blood 
its  red  color. 

The  red  blootl  corpuscles  number  ai)i)roximately  r),()()0,0()0 
to  each  cubic  millimeter  of  blood  and  their  chief  function  is 
the  carrying  of  oxygen  from  the  lungs  to  the  body  tissues. 
If,  as  a  result  of  hemorrhage  or  other  cause,  their  nimiber 
falls  greatly  below  nt)rmal,  the  patient  is  said  to  be  anemic. 
If  the  blood  corpuscles  become  too  few  in  number  life 
ceases. 


Fig.  14. — Human  rod  blood  corpuscles.  Highly  magnified.  a,  seen 
from  the  surface;  6,  seen  in  profile  and  forming  rouleaux;  c,  rendered  spheri- 
cal by  water;  d,  rendered  crenate  by  salt  solution.     (Gray.) 


In  addition  to  the  red  })lood  corpuscles,  there  are  other 
corpuscles  found  in  the  blood  which  are  colorless  and  are 
called  leukocytes,  or  white  blood  corpuscles.  These  are  less 
numerous  than  the  red,  the  average  number  being  5000 
corpuscles  per  cubic  millimeter.  The  leukocytes  are  chiefly 
concerned  in  the  protection  of  the  body  against  infection. 
They  migrate  tlirough  the  walls  of  the  bloodvessels  and  attack 
bacteria  which  invade  the  body,  for  this  reason  being  some- 
times called  phagocytes. 

^Yhen  blood  is  allowed  to  stand  outside  the  vessels  of  the 
body,  it  divides  itself  into  two  portions,  a  thick  spongy  part 
which  is  kn()\^n  as  the  clot  and  a  clear  straw-colored  fluid 


THE  BLOOD  AND  CIRCULATION 


45 


which  is  called  serum.  This  change  is  very  important,  as 
it  is  this  process  of  coagulation,  or  clotting,  whic:h  takes 
place  when  small  bloodvessels  are  cut,  the  clot  forming  a 
plug  which  stops  the  hemorrhage. 


Fig.  15. 


-Diagrammatic  sketch  showing  heart  and  the  beginning  of  the 
large  vessels  in  their  position  in  the  chest.     (Hare.) 


The  Heart. — This  is  a  large  muscular  organ  which  pumps 
the  blood  through  the  bloodvessels,  thus  forming  the  circu- 
lation. The  heart  is  located  in  the  left  side  of  the  chest, 
where  its  beat  can  usually  be  felt  a  few  inches  below  the 
left  nipple.  It  is  about  the  size  of  a  man's  fist.  It  is  divided 
longitudinally  into  a  right  and  left  side,  each  of  which  con- 
tains two  cavities,  one  called  the  auricle  and  the  other  the 
ventricle.  The  auricle  on  the  right  side  is  connected  with 
the  ventricle  on  the  right  side  by  an  opening,  guarded  by 


46  AX  ATOMY   AXD   I'lIYSinLOCY 

valves  whicli  i)ennit  the  blood  to  pass  into  the  ventricle 
but  do  not  allow  it  to  be  forced  back  again  into  the  auricle. 
There  is  a  similar  opening  between  the  left  auricle  and  left 
ventricle,  guarded  by  a  similar  valve.  There  is,  however, 
no  opening  between  the  right  and  left  sides  of  the  heart. 
From  the  right  \'entricle  the  blood  is  forced  into  the  pul- 
monary artery,  and  from  the  left  ventricle  into  the  aorta. 
The  mouths  of  both  of  these  arteries  are  guarded  by  valves 
which  allow  the  blood  to  pass  from  the  ventricles  into  the 
arteries,  but  will  not  permit  it  to  flow  in  the  reverse  direction. 

The  adult  heart  contracts  about  seventy-two  times  per 
minute  in  the  average  person.  In  thin  persons  its  beat  may 
often  be  easily  felt  at  the  location  of  the  apex  of  the  heart, 
which  is  about  two  inches  below  and  a  little  to  the  left  of 
the  left  nipple.  In  stout  persons,  and  in  women  who  have 
large  breasts,  it  can  be  felt  just  below  and  to  the  outer  side 
of  the  left  breast.  However,  in  many  persons  it  is  impos- 
sible to  detect  the  beat  by  means  of  touch,  so  that  this  sign 
is  of  limited  aid  in  determining  the  action  of  the  heart. 

If  the  ear  is  applied  to  the  chest  in  this  region  the  examiner 
can  hear,  with  a  little  practice,  the  dull,  muffled  sounds 
made  by  the  contraction  of  the  heart,  and  can,  if  necessary, 
count  the  beats  as  they  occur. 

However,  for  most  practical  purposes,  the  rate  of  the 
heart's  action  is  taken  from  the  pulsation  of  the  radial 
artery  at  the  wrist,  to  which  the  impulse  of  the  action  of  the 
heart  is  transmitted  through  the  bloodvessels.  Conse- 
quently, we  can  count  the  beats  at  the  wrist  where  the  pulsa- 
tion is  termed  the  pulse,  and  we  speak  of  the  pulse  as  being 
seventy-two  beats  to  the  minute  in  the  average  adult. 

In  young  children  the  pulse-rate  may  be  much  faster,  a 
pulse-rate  of  100  in  a  baby  not  being  uncommon.  In  nervous 
individuals  very  slight  causes  may  be  sufficient  to  send  the 
l)ulse  to  100  or  even  considerably  higher. 

The  Arteries. — When  the  blood  leaves  the  heart  it  passes 
into  large  musculofibrous  tubes,  which  divide  into  smaller 
tubes;  these  in  turn  divide  and  subdivide  into  still  smaller 
tubes,  like  the  trimk  and  l)ranches  of  a  tree.  These  tubes 
are  called  arteries  and  serve  to  carry  the  blood  away  from 


THE  BLOOD  AND  CIRCULATION  47 

the  heart.  The  largest  artery,  the  aorta,  gives  oft'  branches 
soon  after  it  leaves  the  heart,  which  pass  up  on  each  side  of 
the  neck  to  supply  the  corresponding  sides  of  the  neck  and 
head.     A  little  farther  along  a  large  artery  is  given  oft'  to 


Fig.  16. — Showing  the  deep  arteries  of  the  forearm.     (Gerrish.) 


48     .  ANATOMY  AND   PHYSIOLOGY 

.siii)i)ly  eacli  ii])i)er  cxtroniity.  These  large  arteries  pass 
down  each  arm,  giving  off  smaller  branches  to  supply  the 
shoulder  and  arm,  to  the  elbow,  where  they  divide  into  two 
arteries,  the  radial  and  the  ulna.  It  is  the  radial  artery 
which  can  be  felt  pulsating  at  the  wrist. 

After  the  aorta  has  gi\'en  oft"  the  large  branches  to  the 
head  and  arms  it  passes  downward  through  the  chest  to 
the  abdomen,  where  it  divides  into  two  large  branches, 
which  i^ass  to  the  two  lower  extremities.  In  the  chest  and 
abdomen  the  aorta  and  its  large  su])(li\'isions  gi^'e  oft'  large 
and  small  branches  to  supply  the  chest  and  the  abdf)men. 
In  the  thigh  the  single  large  artery  passes  downward  to 
about  the  region  of  the  knee,  where  it  divides  into  two 
smaller  arteries. 

The  arteries  usually  run  deeply  situated  in  the  tissues, 
but  in  a  few  pl,aces  they  may  be  fairly  close  to  the  skin. 
When  close  to  the  skin  or  under  observation  in  a  wound  they 
may  be  seen  to  pulsate,  and  if  cut  the  blood  spurts  from 
them  in  bright  red  jets. 

While  the  k)cation  of  the  arteries  is  fairly  constant  they 
are  subject  to  some  variation.  In  general  it  may  be  said 
that  the  smaller  the  artery  the  more  apt  it  is  to  vary  in  its 
location.  It  is  not  uncommon  for  the  radial  artery  to  be 
situated  a  considerable  distance  from  its  normal  location  in 
the  \^Tist.  In  such  cases  the  examiner  is  sometimes  led 
astray,  believing  the  patient  to  be  pulseless  when  the  true 
condition  is  that  the  abnormal  position  of  the  artery  makes 
it  difficult  or  impossible  to  locate. 

The  walls  of  the  arteries  are  thick,  strong,  and  elastic. 
They  stand  open  when  cut,  in  contradistinction  to  the 
veins,  which  are  soft  and  ftaccid,  and  collapse  unless  filled 
witli  blood. 

The  Capillaries. — As  the  arteries  di\'ide  and  subdivide  they 
continually  grow  smaller,  forming  very  small  arteries,  the 
arterioles,  which  in  turn  divide  into  minute  thin-walled 
vessels,  the  capillaries.  The  walls  of  these  minute  vessels 
are  so  thin  that  the  exchange  of  oxygen  from  the  blood  for 
the  carbon  dioxide  and  waste  products  of  the  tissue  cells 
easily  takes  place.     The  minute  network  of  the  capillaries 


THE  BLOOD  AND  CIRCULATION  49 

passes  to  every  portion  of  the  body,  so  that  even  the  sHght- 
est  scratch  injures  many  of  these  small  vessels. 

The  Veins. — ^The  capillaries  join  together,  forming  larger 
vessels  which  are  termed  veins.  These  veins  again  join  to 
form  still  larger  veins,  finally  forming  the  large  veins  of  the 
extremities  and  other  portions  of  the  body,  which  empty 
into  the  still  larger  veins  of  the  trunk,  finally  emptying  into 
the  right  auricle  of  the  heart.  The  veins  are  less  constant 
in  their  location  and  size  than  are  the  arteries,  and  do  not 
pulsate.  They  are  divided  into  two  groups  according  to 
their  location,  the  superficial,  and  deep,  veins. 

The  deep  veins,  as  a  rule,  accompany  the  arteries,  the  blood 
flowing  in  the  opposite  direction.  Usually  two  veins  accom- 
pany each  of  the  larger  arteries. 

The  superficial  veins  run  in  the  subcutaneous  tissue.  In 
thin  persons  they  can  be  easily  made  out  just  beneath  the 
skin.  Because  they  lie  so  close  to  the  skin  they  are  frequently 
injured  by  comparatively  slight  wounds.  The  blood  in  the 
veins  flows  in  a  steady  stream,  and  is  darker  in  color  than 
that  in  the  arteries. 

When  either  an  artery  or  a  vein  is  divided,  bleeding 
usually  occurs  from  both  the  proximal  and  distal  portions 
of  the  injured  vessel. 

The  Circulation. — The  flow  of  blood  forms  a  complete 
circuit.  Beginning  at  the  right  auricle,  where  the  ^'enous 
blood  enters  the  heart,  it  passes  into  the  right  ventricle, 
which  contracts,  forcing  the  blood  through  the  pulmonary 
artery  to  the  capillaries  in  the  lungs,  where  it  gives  off 
carbon  dioxide  and  takes  up  oxygen.  The  capillaries  of  the 
lungs  join  together  to  form  the  pulmonary  veins,  tlirough 
which  the  now  oxygenated  blood  passes  to  the  left  aiu-icle. 
From  the  left  auricle  the  blood  passes  to  the  left  ventricle, 
which  contracts  and  forces  it  into  the  aorta,  and,  tln-ough 
the  aorta,  to  all  the  smaller  arteries  and  finally  to  the 
capillaries,  where  the  interchange  between  the  blood  and 
tissues  takes  place.  The  blood  passes  on  tln-ough  the  capil- 
laries into  the  veins,  which  finally  carry  it  back  to  the  right 
auricle,  and  the  circuit  is  completed.  This  process  is  repeated 
hundreds  of  times  during  the  day. 
4 


50 


AXATOM)'    AM)   I'llYSlOLOGY 


Median  cephalic 

External     /; 
cnUmeous  uerie. 


^/ 


:-|- 


FiG.  17.— Front  view  of  the  super-  Fig.  18.— Superficial  veins  of  the 

ficial  veins  of  the  arm,  forearm,  and         front  and  inner  surface  of  the  lower 
hand.  extremity.     (Gray.) 


PLATE    II 


I'li/iiKiiiii ri/  <  'ajji/lii I'ii's 


Diagram  to  Show   the    Course  of  the    Circulation 
of  the    Blood. 

The  pulmonary  capillaries  are  the  small  vessels  of  the 
lungs.  The  systemic  capillaries  represent  tViose  of  the  skin, 
head  and  extremities.  The  third  systeni  shown  represents 
the   capillaries   of  the   intestmes  and    liver. 


THE  NERVOUS  SYSTEM 


51 


THE    NERVOUS    SYSTEM. 

All  voluntary  movements  and  many  of  the  involuntary 
functions  of  the  body  are  under  the  control  of  the  nervous 
system.  It  is  tlu'ough  the  medium  of  the  nerves  that  all  the 
impulses  arising  outside  of  the  body  become  sensory  percep- 


CERE 

BRUM      V 


Fig.  19. — Diagrammatic  sketch  of  brain  and  spinal  cord.     (Gerrish.) 


tions.  Even  the  simplest  voluntary  movement,  such  as 
picking  up  a  book  or  drawing  a  straight  line,  is  the  result 
of  a  great  number  of  coordinate  nerve  impulses.  The  sen- 
sation of  taste,  smell,  sight,  and  hearing  are  all  due  to  impres- 
sions made  upon  the  brain  through  the  mediimi  of  corre- 
sponding nerves.  The  nervous  system  is  divided  into  the 
brain,  the  spinal  cord,  and  the  nerves. 


r.9 


ANATOMY  AND  PHYSIOLOGY 


Fig.  20.-Nerves  of  the  skin  of  the  palm  ..f  the  hand  and  arm.     (Gray.) 


THE  NERVOUS  SYSTEM 


53 


The  Brain, — ^This  large  solid  organ,  located  in  the  skull, 
is  the  seat  of  the  mind  and  the  origin  of  voluntary  impulses. 


It  is  made  up  of  cells  and  nerve  fibers.    Any  injiu-y  to  the 
brain  is  serious  because  it  may  interfere  with  the  mind  or 


"54  ANATOMY  AND  PHYSIOLOGY 

with  tlie  ability  to  perforin  voluntary  actions.  Certain 
centers  which  control  \ital  functions,  for  example,  respira- 
tion, are  located  in  the  brain.  If  such  a  center  is  injured 
death  folloM's  as  an  innnediate  result.  The  brain  is  com- 
posed of  the  cerebrum,  which  is  the  larger  portion,  and  is 
located  ixhow  and  anteriorly,  and  the  smaller  portion,  the 
cerebellum,  which  is  posterior  and  below. 

Just  below  the  cerebellum  is  a  prolongation  of  the  brain 
in  the  shape  of  a  truncated  cone,  the  base  being  continuous 
with  the  brain  and  the  apex  with  the  spinal  cord.  This  is 
the  medulla  oblongata,  and  in  it  are  found  the  vital  centers 
hn-  the  control  of  respiration  and  the  action  of  the  heart. 

The  Spinal  Cord. — Passing  from  the  lower  end  of  the 
medulla  and  continuous  with  it  is  the  si)inal  cord,  which  is 
about  the  size  of,  or  a  little  larger  than,  a  lead-pencil.  It 
is  composed  of  nerve  fibers  and  cells.  It  is  located  in  the 
canal  which  is  formed  by  the  openings  in  the  vertebriP,  the 
spinal  canal,  and  gives  ofl  fibers  which  go  to  make  up  the 
peripheral  nerves,  the  fibers  branching  off  the  spinal  cord 
and  passing  outward  through  the  spaces  between  the 
vertebrae. 

The  Nerves. — Arising  both  fi-om  the  brain  and  the  spinal 
cord  are  ner\'e  fibers  which  form  the  peripheral  nerves. 
They  are  grouped  together  in  bundles,  which  vary  in  size 
from  the  minutest  microscopic  fibers  to  bundles  of  fibers  as 
large  as  the  little  finger.  These  nerve  bundles  are  called 
the  peripheral  nerves,  and  the  largest  bundles  are  given 
special  names.  They  divide  and  subdivide  so  that  every 
portion  of  the  body  is  supplied  with  nerve  filaments.  Nerves 
are  of  two  general  types,  the  sensory,  which  carry  impulses 
from  the  periphery  to  the  brain,  and  the  motor  nerves, 
which  carry  impulses  from  the  brain  to  the  muscles.  Most 
large  nerves  contain  both  motor  and  sensor}'  fibers. 

TJw  Action  of  the  Nerves. — This  is  usually  very  compli- 
cated even  for  the  simplest  voluntary  action.  For  the  pur- 
pose of  description  the  nerves  may  be  likened  to  electric 
wires  and  the  brain  to  the  battery.  A  nerve  impulse 
originated  in  the  peripheral  ending  of  a  sensory  nerve  is 
transmitted  to  the  brain,  where  it  is  transformed  to  a  motor 


rilE  NERVOUS  SYSTliM 


55 


impulse,  and  this  motor  impulse  is  transmitted  to  a  muscle 
which  contracts,  resulting  in  motion.     If,  for  example,  the 


LUMBAR    GANCLfA 


Fig.  22. — Spinal  cord  showing  nerve  roots.     (Gerrish.) 


56 


ANATOMY  AND  PHYSIOLOGY 


hand  is  burned  the  sensation  is  transmitted  at  onee  to  the 
brain  and  the  proper  motor  impulse  started  ^^■hich  results 


Fig.  23. — Diagrammatic  sketch  showing  the  course  of  a  nerve  impulse. 
V,  visual  center;  A,  auditory  center;  W,  writing  center;  Z',  vocal  center; 
a  and  v  are  sensory  fibers  conducting  sound  and  visual  perception;  s,  s'  and 
s",  are  sensory  nerve  fibers  from  the  skin  of  the  mouth,  hand  and  ej'e;  m 
and  711'  are  motor  fibers  to  the  mouth  and  to  the  hand.  The  nerve  impulse 
may  Ije  traced  as  follows:  The  object  is  seen  and  the  impulse  carried  to 
the  visual  center  and  transmitted  to  the  writing  center  which  starts  the 
impulse  to  the  hand  which,  under  the  action  of  the  impulse,  writes  the  word. 
In  the  same  way  the  name  of  the  object  seen  may  be  spoken;  or  the  impulse 
may  start  by  a  sense  of  touch  or  hearing  and  result  in  any  form  of  volunlary 
action. 


in  the  hand  beino;  drawn  away  from  the  hot  object.  This  is 
done  so  quickly  that  it  ai)i)ears  as  though  the  action  and 
the  sensation  occurred  simultaneously,  but,  as  a  matter  of 


THE  NERVOUS  SYSTEM  57 

fact,  there  is  an  apprecial)le  time  elapsing  between  the 
moment  the  sensation  originates  and  the  movement  of  the 
hand. 

If  the  impulse  is  interrupted  at  any  point  the  nerve  reac- 
tion will  be  without  result.  Thus,  if  the  sensory  nerve  going 
to  the  hand  has  been  cut,  the  hand  may  be  severely  burned 
without  any  sensation  being  felt.  If  the  sensory  nerve  is 
intact,  but  the  motor  nerve  is  cut,  the  burn  is  felt,  but  there 
is  an  inability  to  withdraw  the  hand. 

The  sensory  impulse  may  arise  as  a  result  of  one  of  the 
special  sensations.  Thus  we  shut  the  eyes  when  a  bright 
light  is  flashed  in  them,  and  we  jump  when  a  loud  noise  is 
heard. 

While  the  brain  is  the  seat  of  all  conscious  action,  con- 
sciousness is  not  essential  to  reflex  action.  The  foot  is 
withdrawn  when  pinched  or  pricked  with  a  pin,  and  the 
eye  is  closed  tightly  when  touched  with  a  feather,  even  in 
people  who  are  unconscious  or  asleep.  This  is  known  as  a 
reflex  act.  The  deeper  the  sleep  or  state  of  unconsciousness 
the  less  marked  are  these  reflex  acts.  Thus,  when  a  patient 
is  anesthetized  the  fact  that  there  is  a  reflex  closure  of  the 
eye  on  lifting  the  lid  and  touching  the  eyeball  is  a  sign  that 
the  patient  is  not  deeply  anesthetized.  In  the  same  way 
the  closure  of  the  lid  and  the  reaction  of  the  pupil  to  the 
action  of  light  may  be  used  to  indicate  the  degree  of  uncon- 
sciousness following  injury. 

In  addition  to  the  peripheral  nerves  just  described  there 
exists  in  the  body  a  secondary  system,  nerves  which  arise 
in  nerve  centers  located  chiefly  in  the  chest  and  abdomen, 
the  sympathetic  system.  Centrally,  these  centers  are  con- 
nected with  the  nerves  leaving  the  spinal  cord  and  distally 
they  send  fibers  to  the  organs  of  the  abdomen  and  chest  and 
to  the  bloodvessels  of  the  entire  body. 

While  the  action  of  the  heart  and  the  processes  of  diges- 
tion are  to  a  certain  degree  automatic  they  are  at  the  same 
time  under  the  control  of  the  s^nipathetic  nervous  system. 
Thus  the  mere  sight  of  food  is  enough  to  cause  salivation 
and  the  secretion  of  gastric  juice,  while  an  unpleasant  sight 
may  cause  faintness  and  nausea. 


58 


ANATOMY  AXD   PHYSIOLOGY 


The  relation  of  the  nervous  system  to  the  general  physieal 
eonclition  will  receive  further  consideration  in  reference  to 
syncope  and  shock. 


VESTIBULC 


Fig.  24. — Section  through  the  head  and  neck  showing  cavities  of  the 
throat  and  nose,  beginning  of  the  trachea,  and  the  larynx.     (Gerrish.) 


THE  RESPIRATORY   SYSTEM. 

The  respiratory  system  consists  of  the  nasal  passages,  the 
larynx,  the  trachea,  the  bronchi,  and  the  lungs. 

The  Nose. — Air  is  admitted  to  the  body  through  the  nose, 
which  consists  of  the  external  nose  and  the  nasal  passages. 
The  nasal  passages  are  two  in  number,  separated  by  a  thin 
partition,  the  nasal  septum.  In  its  passage  through  the 
nose  the  air  is  warmed  and  a  certain  amount  of  dust  and 
other  extraneous  material  is  removed.  If  the  air  is  dry  it 
receives  sufficient  moisture  in  the  nose  to  render  it  less 
irritating  to  the  lungs. 


THE  RESPIRATORY  SYSTEM 


59 


The  Larynx. — The  air  passes  from  the  nasal  passages 
through  the  throat  into  the  larynx,  which  is  situated  at  the 
beginning  of  the  trachea.  The  larynx  is  located  just  behind 
the  base  of  the  tongue,  and  during  the  act  of  swallowing  it 
is  covered  with  a  thin  fibrous  flap,  the  epiglottis,  which 
prevents  the  entrance  of  food  into  the  trachea.  The  larynx 
contains  the  vocal  cords,  which  are  instrumental  in  producing 
the  voice. 


Vallecula 


Median  glosso  c2ngloUic  fold 
E'piglottis 

fTuhercle  of  epiglottis 
Vocal  fold 


Ventricular  fold 

A  ry epiglottic  fold 
Cuneifonn  cartilage 


Corniculate  cartilage 


Trachea 
Fig.  25. — Showing  larynx  and  vocal  cords  from  above. 


(Gray.) 


The  Trachea. — Below  the  laryixx  is  a  firm  tube-like  struc- 
ture, the  trachea,  which  passes  downward  in  the  midline 
and  can  be  felt  in  the  lower  anterior  portion  of  the  neck. 
The  trachea  acts  as  a  passageway  for  the  air  between  the 
larynx  and  the  bronchi,  and  is  about  one-half  inch  in  diameter 
and  several  inches  long. 

The  Bronchi. — ^The  trachea  divides,  in  the  upper  part  of 
the  chest,  into  two  similar  though  smaller  tubes,  one  to 
each  lung.  These  are  the  two  main  bronchi.  These  divide 
and  subdivide  into  smaller  bronchi,  the  smallest  of  which 
are  termed  bronchioles.  In  this  manner  the  air  is  distributed 
to  all  parts  of  the  lungs. 

The  Lungs. — The  bronchi  gradually  become  smaller,  end- 
ing in  minute  air  cells  where  the  interchange  of  oxvgen  takes 


GO  ANATOMY  AND  PHYSIOLOGY 

place  between  the  insi)ired  air  and  the  blood.  The  minnte 
air  cell  has  a  very  thin  wall  which  is  in  direct  contact  with 
the  small  capillaries  of  the  lungs.  The  blood  and  air  do  not 
mix  but  the  oxygen  and  carbon  dioxide  pass  freely  through 
the  thin  layer  of  membrane  separating  the  two. 

Respiration. — The  air  is  drawn  into  the  chest  by  suction. 
The  ribs  are  raised  and  the  flat  fibromuscular  diaphragm, 
which  separates  the  chest  from  the  abdomen,  is  drawn  down- 
ward so  that  the  cavity  of  the  chest  is  enlarged  and  the  air 
rushes  in  to  fill  the  space,  in  the  same  manner  as  air  rushes 
into  the  chamber  of  a  pump  when  the  piston  is  withdrawn. 
The  lungs  themselves  act  simply  as  inert  sacs  which  expand 
as  the  air  rushes  in.  This  is  called  inspiration.  The  ribs 
now  descend  and  the  diaphragm  mo\'es  upward  and  the  air 
is  forced  out.  This  is  called  expiration.  The  combination 
of  the  two  methods  constitute  the  act  of  breathing  or 
respiration.  Both  inspiration  and  expiration  are  controlled 
to  a  slight  degree  by  the  will.  When  respiration  ceases  for  a 
period  of  more  than  two  or  three  minutes,  changes  take 
place  in  the  body  cells  that  soon  result  in  death.  It  is 
impossible  to  say  how  long  respiration  may  cease  before 
death  occiu-s.  Apparently  reliable  reports  have  appeared 
from  time  to  time  in  which  recovery  has  taken  place  after 
respiration  has  been  absolutely  absent  for  five  minutes  or 
longer.  In  most  cases,  however,  cessation  of  respiration  for 
more  than  a  very  short  time,  three  to  five  minutes,  results 
in  death. 

In  health  the  rate  of  respiration  varies  from  14  to  24  per 
minute.  In  disease  the  rate  may  be  as  low  as  8  and  as 
high  as  60.  Both  of  these  extremes  indicate  serious  dis- 
turbances. In  children  the  respiration-rate  is  more  rapid, 
the  normal  being  considerably  higher  than  in  adults.  In 
cases  of  pneumonia  it  is  not  uncommon  to  see  a  child  with  a 
respiration  of  (iO  or  higher  make  a  complete  recovery. 

Physiologically,  the  respiration  is  increased  by  exertion 
and  the  breathing  of  rarefied  air,  such  as  occurs  in  high 
altitudes. 


THE  ABDOMEN  61 

THE  ABDOMEN. 

The  lower  half  of  the  trunk  is  known  as  the  abdomen. 
In  it  are  found  the  organs  of  digestion,  the  liver,  the  spleen, 
and  the  kidneys. 

The  Alimentary  Canal. — Digestion  of  food  takes  place 
almost  entirely  within  the  alimentary  canal.  It  begins  in 
the  mouth  and  is  continued  in  the  stomach  and  the  small 
and  large  intestines.  The  food  is  taken  into  the  mouth, 
where  it  is  broken  up  and  mixed  with  the  secretions  of  the 
salivary  glands  before  it  is  swallowed.  It  then  passes 
through  a  long  tube,  the  esophagus,  or  gullet,  to  the  stomach, 
where  it  is  mixed  with  the  gastric  juice.  The  process  of 
digestion  is  continued  in  the  small  intestine,  and  the  nutri- 
tive products  of  digestion  are  absorbed  through  the  walls  of 
the  small  and  the  large  intestines. 

The  Stomach. — The  stomach  is  a  musculomembranous  sac 
holding  about  two  or  three  pints  and  located  in  the  upper 
part  of  the  abdomen.  The  food  remains  in  the  stomach 
for  a  period  varying  from  a  few  minutes  to  two  or  three 
hours  before  passing  into  the  intestines.  This  fact  is  impor- 
tant, because  in  case  of  poisoning  the  poison  may  be  almost 
entirely  removed  if  the  stomach  is  emptied  during  the  half- 
hour  immediately  following  the  ingestion  of  the  poisonous 
substance. 

The  food  passes  out  of  the  stomach  into  the  small  intes- 
tine, which  is  a  flaccid  musculomembranous  tube  about 
twenty  feet  in  length.  This  tube  connects  with  a  similar 
one  about  six  or  seven  feet  in  length,  the  large  intestine. 
The  latter  in  turn  ends  in  the  rectum.  During  its  passage 
through  the  small  and  large  intestines  the  food  undergoes 
further  digestion  and  the  digested  material  is  absorbed,  the 
food  fibers  and  other  indigestible  portions  of  food  remaining 
in  the  intestinal  canal  to  be  excreted  in  the  process  of 
defecation. 

The  Liver. — In  the  right  upper  portion  of  the  abdomen  is 
a  large  reddish-brown  organ,  weighing  about  tlu-ee  or  four 
pounds,  the  liver.  It  is  a  solid  organ  made  up  almost  entirely 
of  liver  cells,  which  secrete,  bile.     Most  of  the  blood  carrv- 


62 


AXATOMY  AXD   PHYSIOLOGY 


ing  the  absorbed  pri)duets  of  digestion  passes  through  the 
liver  before  it  enters  the  general  cireuhition.     During  its 


Fig.  26. — The  front  view  of  the  abdominal  contents.  The  liver  has  been 
lifted  upward  to  show  the  stomach  and  gall-bladder.  The  large  intestine 
(colon)  may  be  seen  running  upward  on  the  right  side,  (hen  across  the  abdo- 
men and  downward  on  the  left.     (Gerrish.) 


THE  ABDOMEN 


63 


passage  through  the  hver  the  blood  undergoes  certain 
chemical  changes  which  are  not  very  clearly  understood 
but  Avhich  are  essential  to  life.     In  crushing  accidents  the 


HEPATIC 

VEINS  INFERIOR    PHRENIC 

ARTERIES 


CESOPHAGUS 


SUPER 
MESENTE 
ARTE 


INFERI 
MESENTEF 
ARTEF 


COMMC 

ILIAC  ARTEF 

AND  VEI 


INTERNAL 
SPERMATIC 
^^       ARTERY 
^^      AND  VEIN 
i^^      INTERNAL 
"       —  ILIAC   ARTERY 


M      AND   URETER 


Fig.  27. — Showing  the  kidneys  and  great  vessels  of  the  abdomen  in  their 
normal  position.  The  stomach,  liver,  and  intestines  have  been  removed. 
(Gray.) 


64  ANATOMY  AND  PHYSIOLOGY 

liver   is   sometimes   ruptm'ed,    hemorrhage   from    tlic   torn 
tissue  being  very  jirofuse. 

The  Kidneys. — Located  in  the  back  part  of  the  abdominal 
caxity,  one  on  each  side  of  the  spine,  are  two  bean-shaped' 
glandular  organs,  the  kidneys.  Each  weighs  about  five 
ounces.  They  excrete  the  urine,  that  is,  they  remove  the 
excess  of  water  and  the  waste  products  from  the  blood  by  a 
process  which  is  partly  filtration  and  ])artly  selected  cellular 
secretion.  The  urine  passes  from  each  kidney  through  a 
narrow  tube  about  twelve  inches  in  length,  the  ureter,  to 
the  l)ladder. 

The  Bladder. — The  urine  passes  through  the  two  ureters 
into  a  musculomembranous  sac,  the  bladder,  which  serves 
simply  as  a  temporary  storehouse  for  the  urine.  It  will 
hold  ordinarily  a  pint  or  more  and  is  partially  under  volun- 
tary control.  When  full  it  may  be  ruptured  by  crushing 
injuries  or  by  falls,  allowing  the  urine  to  escape  into  the 
abdominal  cavity. 

The  Peritoneum. — Most  of  the  organs  of  the  abdomen  are 
covered  by  a  thin,  serous  membrane,  the  peritoneum,  which 
is  kept  constantly  moist  by  a  serous  secretion  of  jx'ritoneal 
fluid.  The  organs  are  thus  allowed  to  move  upon  each  other 
without  friction. 

When  the  intestines,  the  bladder,  or  any  other  hollow 
organ  is  ruptured  the  contents  escape  into  the  general 
abdominal  cavity  and  come  into  contact  with  the  peritoneal 
covering  of  these  organs,  resulting  in  peritonitis. 

Owing  to  the  fact  that  communication  with  all  parts  of 
the  peritoneal  cavity  is  free,  the  spread  of  infectious  material 
is  apt  to  be  \'ery  rapid. 

The  Reproductive  Organs. — The  organs  of  reproduction,  in 
both  male  and  female,  are  located  partially  within  the 
pelvis  and  partially  external  to  the  pelvis  on  the  lower 
part  of  the  trunk.  Owing  to  the  abundant  nerve  supply  of 
these  organs  injury  is  apt  to  result  in  pain  and  evidences 
of  shock,  out  of  all  proportion  to  the  apparent  severity  of 
the  injury  received. 


CHAPTER   HI. 
WOUNDS  AND  WOUND  INFECTION. 

CONTUSIONS. 

When  an  injury  has  been  caused  by  a  blow  with  a  bhnit 
object  without  laceration  of  the  overlying  skin  it  is  called 
a  contusion  or  bruise.  The  result  is  a  crushing  injury  to  the 
tissues,  associated  with  hemorrhage  beneath  the  skin,  which 
later  becomes  apparent  in  the  familiar  "black-and-blue" 
spot.  This  area  of  hemorrhage  beneath  the  skin  is  known  as 
ecchymosis,  or  snhcutaneous  hemorrhage. 

Depending  upon  the  depth  of  the  hemorrhage,  the  ecchy- 
mosis appears  at  a  variable  time  after  the  injury,  and  is 
most  pronounced  where  the  skin  and  tissues  are  very  loose. 
Thus,  about  the  eye,  where  the  bleeding  is  immediately 
beneath  the  skin  and  the  tissues  are  very  loose,  a  compara- 
tively slight  injury  may  result  in  a  large  area  of  discolora- 
tion, which  appears  within  a  few  hours.  In  the  arms  and 
legs  it  may  take  the  blood  a  long  time  to  reach  the  skin; 
that  is,  the  black-and-blue  spot  does  not  appear  at  once 
but  only  after  two  or  three  days. 

Treatment. — Contusions  are  usually  painful  for  several 
days  and  tender  to  pressure  for  a  few  days  longer.  The 
black-and-blue  spot  gradually  becomes  less  distinct  and 
disappears  after  about  two  weeks.  In  examining  a  patient 
a  contusion  is  felt  as  a  tender  spot.  It  is  the  familiar  bruise, 
which  is  so  commonly  seen,  and  requires  little  or  no  first- 
aid  treatment.  If  you  are  sure  that  there  is  no  fracture  or 
deeper  injury  the  bruise  itself  may  usually  be  disregarded. 
If  the  pain  is  very  severe,  bathing  in  cold  water  or  the 
application  of  cloths  dipped  in  cold  water  will  give  relief. 
The  absorption  of  the  blood  in  the  tissues  may  be  hastened 
after  the  second  day  by  the  use  of  hot  baths  and  hot  com- 
5 


66  WOUNDS  AND   WOUND  INFECTION 

presses  in  place  of  cold.  If  the  contusion  has  been  very 
extensive,  rest  in  bed  or  rest  of  the  part  by  use  of  a  sling 
will  afi'ord  considerable  relief. 

If  a  bruise  appears  to  be  unusually  painful  a  ])hysician 
should  be  called  to  examine  for  fracture  or  other  injury  to 
the  deeper  parts.  In  accidents  the  injured  i)erson  rarely 
complains  of  an  ordinary  contusion.  They  only  become 
aware  of  the  bruise  after  several  hours  when  they  notice 
stiffness  and  pain.  If,  after  an  injury,  a  patient  applies  for 
treatment  immediately,  the  surgeon  suspects  an  injury  to 
the  deeper  parts;  but  if  he  does  not  com])lain  of  pain  imtil 
the  next  day,  and  then  the  disability  is  ^■ery  slight,  there  is 
probably  only  a  contusion  and  little  possibility  of  serious 
injury. 

Contusions  of  the  head,  chest,  or  abdomen  have  a  special 
significance,  and  will  be  referred  to  later. 

WOUNDS. 

A  wound  is  a  separation  of  the  soft  parts  of  the  body, 
associated  with  incision  or  laceration  of  the  skin  or  mucous 
membrane.     They  are  divided  into  four  general  types: 

1.  Contused  icounds,  made  with  blunt  instruments;  there 
is  a  contusion  associated  with  a  wound  of  the  skin,  usually 
bursting  or  tearing  in  character. 

2:  Inched  wounds,  those  made  with  a  knife  or  other  sharp- 
cutting  instrument. 

3.  Lacerated  wounds,  torn  or  jagged  wounds  made  with 
rough,  irregularly  shaped  instruments. 

4.  Punctured  woiinds,  made  by  sharp-pointed  instruments. 
The  characteristics  of  all  wounds  are  pain,  tenderness, 

and  hemorrhage.  The  type  of  wound  is  at  once  apparent 
on  inspection. 

Treatment. — Wounds  are  the  most  common  injuries  that 
the  first-aid  worker  is  required  to  treat,  and  the  imj^ortance 
of  proper  emergency  treatment  cannot  be  too  strongly 
emphasized.  It  is  here  that  first  aid  accomplishes  its  great- 
est work.  Every  single  injury  of  the  skin  and  tissues  which 
causes  bleeding  externally,  from  the  smallest  pin-prick  or 


HEMORRHAGE  67 

abrasion  (a  superficial  wound  of  the  skin)  to  the  terrible 
lacerations  of  the  extremities,  is  a  wound;  and  each  and  every 
one  should  receive  the  most  painstaking  care. 

Cases  are  not  rare  where  lack  of  care  following  an  insignifi- 
cant injury,  such  as  an  abrasion  or  a  small  punctured  wound, 
has  resulted  in  blood-poisoning  and  death;  and  there  have 
been  many  cases  in  which  intelligent  emergency  treatment 
has  not  only  prevented  fatal  hemorrhage  but  has  kept  the 
wound  clean  and  sterile,  so  that  secondary  infection  did  not 
occur. 

There  are  three  specific  requirements  for  the  successful 
treatment  of  wounds: 

1.  The  arrest  of  hemorrhage. 

2.  The  prevention  of  infection. 

3.  The  restoration  of  function. 

For  the  first-aid  worker  the  arrest  of  hemorrhage  and  the 
prevention  of  infection  are  the  most  important.  The  restora- 
tion of  function  is  largely  in  the  hands  of  the  surgeon, 

HEMORRHAGE. 

Hemorrhage  means  bleeding.  The  term  is  not  confined 
to  serious  and  prolonged  bleeding,  but  it  is  applied  to  bleed- 
ing of  every  sort.  It  may  be  due  to  the  division  of  a  number 
of  capillaries,  when  it  is  usually  mild,  or  to  the  division  of 
larger  vessels,  either  arteries  or  veins,  in  which  case  it  is 
more  difficult  to  control. 

Capillary  Hemorrhage. — Capillary  hemorrhage  is  the  slow 
oozing  which  comes  from  the  exposed  surface  of  a  wound. 
If  this  surface  is  swabbed  free  of  blood  there  can  be  found 
no  special  bleeding-point,  but  the  entire  surface  seems  to 
exude  blood.  The  total  amount  may  be  considerable  but 
never  enough  to  endanger  the  life  of  the  patient.  Hemor- 
rhage which  is  purely  capillary  in  character  stops  after  a 
few  minutes.  When  it  is  desired  to  stop  it  sooner  a  pad  of 
sterile  gauze  is  pressed  against  the  bleeding  surface  and  held 
in  place  for  a  minute  or  two,  or  bound  in  place  with  a  ban- 
dage. Hemorrhage  of  this  type  may  be  almost  disregarded 
because  it  is  stopped  by  the  application  of  the  dressing. 


68  WOUNDS  AXD   WOrXD   IXFECTION 

Venous  Hemorrhage. — Tliis  form  of  liemorrliagc  is  apt  to 
be  \"cry  i)rofusc.  If  a  large  vein  is  cut  a  patient  may  bleed 
to  death,  but,  as  a  rule,  the  thin  wall  of  the  vein  collapses 
and  the  hemorrhage  eeas(>s  automatically.  The  blood  from 
a  vein  is  darker  than  that  from  an  artery,  and  it  flows 
slowly  and  steadily.  Both  ends  of  the  di^'ided  vessels  bleed 
freely,  but  the  distal^  end  is  apt  to  bleed  more  than  the 
proximal.  Direct  pressure  applied  to  the  bleeding-point 
will  sto])  venous  hemorrhage. 

Arterial  Hemorrhage. — AYhen  an  artery  is  cut  the  bright 
red  blood  spurts  in  jets  from  the  wound.  This  is  charac- 
teristic of  arterial  hemorrhage  but  in  some  cases  the  end  of 
the  vessel  may  be  deep  in  the  wound  so  that  the  spurting 
is  not  evident.  As  in  acuous  hemorrhage,  both  ends  of  the 
divided  vessel  bleed  freely  but  in  this  case  the  hemorrhage 
is  most  marked  from  the  end  nearest  the  heart.  Bleeding 
from  small  arteries  will  stop  after  slight  pressure.  Only  in 
the  larger  arteries  is  a  special  method  required  to  control 
the  hemorrhage. 


METHODS    OF    CONTROLLING   HEMORRHAGE. 

Remembering  that  a  little  blood  makes  a  great  show,  the 
first  step  is  to  determine  how  se^'ere  the  bleeding  is.  In 
some  cases  the  face  and  hand  ma}'  be  entirely  covered  with 
blood  when  the  bleeding  itself  has  entirely  stopped.  Locate 
definitely  the  bleedmg-point  before  attemptmg  to  stop  the 
hemorrhage.  I  have  seen  a  patient  at  death's  door  as  a 
result  of  hemorrhage  from  a  ruptured  varicose  vein,  simply 
because  no  one  had  the  intelligence  to  look  for  the  bleeding- 
point.  In  this  case  the  foot  was  almost  covered  with  blood 
and  the  first-aid  enthusiast  had  carefully  AM-apped  a  sheet 
about  the  foot  AA'ithout  noticing  that  the  blood  came  from 
a  point  higher  up  the  leg.  In  addition  to  the  sheet  wrapped 
about  the  foot,  a  tourniquet  had  been  applied  about  the 
thigh  in  such  a  manner  that  the  venous  return  from  the  leg 

1  The  distal  end  is  the  end  farthest  away  from  the  heart.  The  proximal 
end  is  the  end  nearest  the  heart. 


METHODS  OF  CONTROLLING  IIEMORRHAGE        09 

was  stopped  but  the  arterial  flow  was  not  interfered  with. 
When  this  patient  was  seen  all  that  was  required  was  to 
remove  the  tourniquet  and  make  the  patient  lie  down  with 
the  leg  slightly  elevated.  The  bleeding  then  stopped 
spontaneously. 
The  direct  methods  of  controlling  hemorrhage  are: 

1.  Direct  pressure. 

2.  Elevation. 

3.  Application  of  heat  or  cold. 

4.  The  tourniquet. 

5.  Styptics. 

1.  Direct  Pressure. — This  is  the  most  important  method. 
In  any  case  where  pressure  may  be  applied  directly  to  the 
bleeding-point,  hemorrhage  will  stop  as  long  as  the  pressure 
is  continued.  In  operating  the  surgeon  often  divides  fairly 
large  vessels.  When  this  occurs  the  operator  quickly  puts 
his  finger  on  the  bleeding-point,  thus  immediately  stopping 
the  hemorrhage.  The  vessel  is  then  clamped  with  a  specially 
devised  clamp,  or  ligated  at  once.  Even  in  the  arteries  the 
pressure  of  the  blood  is  comparatively  slight,  so  that  if  the 
finger  can  be  placed  over  the  bleeding-point  the  hemorrhage 
can  be  stopped  at  once.  However,  in  ordinary  cases  pressure 
with  the  finger  is  unnecessary.  When  most  wounds  are 
examined  the  hemorrhage  is  found  to  be  slight  or  at  most 
only  moderate.  If  the  blood  is  flowing  in  a  steady  stream, 
it  requires  prompt  attention;  if  it  is  dropping  rapidly,  the 
patient  is  in  no  danger,  but  measures  should  be  taken  to 
stop  the  bleeding  at  once;  if  it  is  dropping  slowly  from  the 
wound,  say  five  or  six  drops  a  minute,  there  is  no  great 
hurry  and  it  is  permissible  to  take  sufiicient  time  to  secure 
the  best  available  material  for  a  dressing. 

Direct  pressure  on  any  bleeding  wound  can  be  secured  by 
the  use  of  a  gauze  compress,  or,  if  one  is  not  at  hand  a  folded 
handkerchief  can  be  used,  care  being  taken  to  use  sterile 
compresses  when  they  are  available. 

A  compress  is  placed  directly  in  the  wound  and  held  firmly 
w4th  the  fingers.  This  will  show  at  once  whether  the  bleed- 
ing is  under  control.  If  not,  another  compress  should  be 
applied  and  this  repeated  until  the  wound  is  firmly  packed 


70 


WOUNDS  AND   WOUND  INFECTION 


with  gauzo.     1  have  rarely  seen  an  emergency  liemorrhage 
whifli  could  not  he  stopped  by  this  method. 

After  the  eoni])resses  are  in  place  a  siuiti"  l)andaii;e  is  api)lied 
directly  over  the  Avound.  Where  the  bleeding  is  j)rot'use,  a 
bandage  may  be  placed  on  \  cry  tightly  and  left  on  for  a  few 
hours  and  then  re})laced  by  a  looser  bandage.  Care  should 
be  taken  not  to  leave  the  tight  bandage  on  too  long,  for 
this  may  result  in  constriction  of  the  i)art  with  secondary 
gangrene. 


Fig.  28. — Flexion  of  the  knee  to  control  hemorrhage  from  the  foot.  The 
knee  i.s  held  in  acute  flexion  by  a  rubber  bandage.  This  method  is  applic- 
able only  to  the  elbow  or  the  knee  in  hemorrhage  from  the  hand  or  foot. 

(Park.) 


Siu-geons  apply  direct  pressure  by  the  use  of  artery  clamps 
and  ligatures.  The  artery  clamp  is  a  specially  designed  instru- 
ment which  is  clamped  over  the  end  of  the  bleeding  vessel, 
holding  it  tightly  closed.  A  ligature  is  a  piece  of  catgut 
string  or  a  silk  thread  which  is  tied  about  the  end  of  the 
bleeding  vessel,  just  as  a  string  might  lie  tied  about  a  rubber 
tube.  Both  the  ligature  and  artery  clamp  are  available 
only  for  advanced  students  in  first  aid  and  are  usually 
unnecessary  in  emergenc}'  w(irk. 


METHODS  OF  CONTROLLING  HEMORRHAGE         71 

2.  Elevation. — This  is  a  valuable  adjunct  to  any  method. 
If  a  bandaged  hand  continues  to  bleed  it  will  often  stop 
when  the  hand  is  held  over  the  head.  When  there  is  bleed- 
ing from  the  foot,  the  patient  is  told  to  lie  down  and  the 
foot  is  raised  well  above  the  body.  In  bleeding  from  the 
nose  the  head  is  kept  erect,  not  bent  forward  over  a  basin. 

3.  Heat  and  Cold. — Water  as  hot  as  it  can  be  borne,  or  ice- 
water,  will  tend  to  stop  hemorrhage.  Before  the  present 
technic  was  perfected  surgeons  sometimes  cauterized  wourtds 
with  a  hot  iron  to  stop  hemorrhage.  Both  heat  and  cold 
are  seldom  used  except  where  a  bandage  cannot  be  applied, 
as  in  the  nose  or  mouth.  In  such  cases  they  may  be  very 
valuable. 


•='*-*«:auii 


Fig.  29. — Piece  of  rubber  tubing  used  as  a  tourniquet.  The  attached 
clamp  holds  the  knot  firm.  The  tubing  would  be  more  effective  if  applied 
above  the  knee. 

4.  The  Tourniquet. — This  is  the  most  widely  known  and 
most  abused  instrument  of  first  aid.  It  is  widely  known 
because  it  is  easily  understood  and  appeals  to  the  popular 
fancy.  It  is  abused  because  it  is  almost  always  wrongly 
appUed.  It  is  only  applicable  to  hemorrhage  from  the 
extremities  and  to  be  correctly  applied  it  must  be  fastened 
tightly  enough  to  stop  the  arterial  flow.  If  applied  less 
firmly,  it  only  acts  to  increase  the  hemorrhage.  I  have  seen 
many  cases  where  a  tourniquet  has  been  applied  in  an  emer- 
gency case  and  I  have  never  seen  a  single  case  where  it 
accomplished  its  purpose.    In  most  cases  where  I  have  seen 


ll'Of'.VD^'  .1A7)    WOIWD  IXFECTIOX 


it  ap])lic(l  all  that  was  irciuiivd  to  stoj)  the  hlcedint;'  was  the 
iviiioxal  ol'  the  tourniquet. 

The  ordinary  directions  for  its  use  are  as  follows:  A  hand- 
kerchief or  strip  of  strong  cloth  is  placed  loosely  about  the 
limb  between  the  wound  and  the  heart  and  the  ends  tied 
together.  A  cloth  jjad  or  hard  object  is  ])laced  over  the 
location  of  the  main  artery  and  a  stick,  i)assed  under  the 

l)and  at  the  opposite  side  of  the 
limb,  is  used  to  twist  the  bandage 
so  as  to  make  the  wad  press  firmly 
against  the  artery.  If  the  location 
of  the  artery  cannot  be  remembered 
the  tourniquet  is  applied  without  the 
pad  against  the  artery. 

From  the  above  description  it  is 
apparent  that  to  corr^^'ctly  apply  a 
toiu'niquet  a  certain  knowledge  of 
anatomy  is  necessary.  As"  it  must 
be  applied  tightly  enough  to  com- 
press the  artery  it  is  only  possible 
to  use  it  in  the  upper  arm  and  thigh. 
In  the  forearm  and  leg,  the  two 
bones  give  sufficient  protection  to 
the  arteries  so  that  they  cannot  be 
conipressed  by  the  ordinary  tourni- 
quet. 

For  a  wound  of  the  hand  or  arm 
where  other  methods  fail  to  control 
the  bleeding  the  tourniquet  should 
be  applied  with  the  pad  on  the  inner 
side  of  the  arm  over  the  brachial 
artery.  For  a  wound  of  the  leg,  where  direct  pressure  w^ith 
bandaging  and  elevation  are  not  sufficient,  the  tourniquet 
is  applied  with  a  pad  about  one  in(;h  })elow  the  midpoint  of 
the  crease  in  the  groin  over  the  femoral  artery. 

In  addition  to  its  other  disadvantages  the  tourniquet  is 
apt  to  lead  to  gangrene  if  left  on  too  long.  After  half  an  hour 
it  should  be  removed  and  left  off  if  possible. 


Fig.  30.— Tourniquet  for 
control  of  bleeding  from  the 
arm.  The  pad  is  placed 
directly  over  the  artery. 


METHODS  OF  CONTROLLING  HEMORRJIAGE         73 

Do  not  be  in  too  much  of  a  hurry  to  use  the  tourniquet; 
use  it  only  as  a  method  of  last  resort. 


Fig.  31. — Location  of  the  principal  arteries.  1,  temporal  artery;  2,  occipi- 
tal artery;  3,  facial  artery;  Jf.,  lingual  artery;  5  and  6,  common  carotid 
artery;  7,  subclavian  artery;  8  and  9,  axillary  artery;  10,  brachial  artery; 
11,  radial  artery;  12,  ulnar  artery;  13,  external  iliac  artery;  llf,  femoral 
artery  in  Scarpa's  triangle;  15,  femoral  artery  in  Hunter's  canal;  16,  ante- 
rior tibial  artery ;  1 7,  posterior  tibial  artery ;  1 8,  posterior  tibial  artery  behind 
the  internal  malleolus;  19,  dorsalis  pedis  artery.  Pressure  to  stop  hemor- 
rhage from  the  leg  should  be  made  at  IJf  or  15;  from  the  arm  at  9  or  10. 
Pressure  at  the  other  points  is  apt  to  be  unsatisfactory. 


74 


WOUNDS  AND   WOUND  INFECTION 


o.  Styptics. — riiemicals  used  to  sto])  lioinorrhage  are 
called  styptics.  Hydrogen  peroxide,  adrenalin,  tincture  of 
ferric  chloride,  alum  and  silver  nitrate  have  all  been  used. 
They  are  rarely  of  service  except  in  small  hemorrhages  about 
the  nose  and  mouth. 


Fig.  32. — Pressure  with  the  thumbs  on  the  femoral  artery  to  stop  hemorrhage 
from  the  thigh  or  leg.     (Wharton.) 


INFECTION    AND    SUPPURATION. 

When  living  pathogenic^  bacteria  are  introduced  into  a 
wound,  it  is  said  to  be  infected.  These  bacteria  may  or  may 
not  cause  inflammation  with  the  formation  of  pus.  If  few 
in  number  they  may  be  killed  by  the  antiseptic  forces  of  the 
body  or  by  antiseptics  used  in  the  treatment  of  the  wound. 
If  they  grow  and  develop  the  wound  becomes  inflamed,  and 
there  is  a  discharge  of  pus.  This  is  called  suppuration. 
Ordinarily,  we  do  not  speak  of  a  wound  as  infected  unless 
the  wound  shows  suppuration. 

Bacteria. — Bacteria,  or  germs,  are  microscopic  organisms, 
so  small  that  many  millions  might  be  lodged  upon  the  head 
of  a  pin.  There  are  hundreds  of  different  varieties,  only  a 
comparatively  few  of  which  cause  disease.  They  grow  very 
rapidly,  a  single  bacterium  increasing  to  many  millions  in  a 
few  days. 

1  Pathogenic  bacteria  are  th(jsc  which  give  rise  to  disease  in  the  human 
body. 


INFECTION  AND  SUI'FU RATION  75 

Bacteria  are  found  almost  everywhere;  in  the  air  we 
breathe,  in  the  water  we  drink,  on  the  surface  of  the  skin, 
and  on  the  outside  of  all  the  objects  we  handle.  Any  object 
which  is  exposed  to  the  air  soon  becomes  covered  with 
many  thousands  of  bacteria.  Even  things  which  appear 
very  clean  and  well  polished  give  lodgment  to  many  bac- 
teria, while  things  which  appear  dirty  and  dusty  are  usually 
literally  swarming  with  germs.  Fortunately  only  a  few  are 
pathogenic,  or  disease  breeding.  These  pathogenic  bac- 
teria are  most  common  where  many  people  are  congregated. 
Thus,  in  theaters,  schools  and  generally  about  populous 
centers  there  are  many  disease  bacteria,  while  in  the  forests, 
on  uninhabited  sea  islands  and  in  the  cold  regions  of  the 
north  they  are  very  rare. 


Fig.  33. — Microscopic  appearance  of  staphylococci.     Magnified  1100 
diameters.     (Park  and  Williams.) 

In  the  European  War  the  battles  were  fought  in  the  fields 
of  northern  France.  The  highly  cultivated  earth  was  simply 
loaded  with  bacteria,  many  of  which  were  of  the  pathogenic 
variety.  The  result  was  that  almost  every  wound  became 
infected.  In  the  Boer  War  the  fighting  was  largely  confined 
to  the  virgin  territory  in  South  Africa  containing  very  few 
pathogenic  bacteria.  Consequently  infected  wounds  were 
less  common  in  the  Boer  War. 

Bacteria  are  divided  into  two  main  groups;  the  bacilli,  or 
rod-shaped  bacteria;  and  the  cocci,  or  round  bacteria.  The 
cocci  are  further  divided  into:    (1)  Streptococci,  which  grow 


76 


WOUNDS  AXD   WOUM)  INFECTION 


in  strings  or  cliains;  (2)  staphylococci,  which  grow  in  bunches; 
(o)  tliplococci,  which  grt)W  in  i)airs.  There  arc  other  general 
forms  l)ut  the  above  are  the  varieties  most  frequently  seen. 


Fig.  34. — Showing  how  streptococci  grow  in  chains.     Magnified  1000 
diameters.     (Hcrzog.) 

INIany  of  the  so-called  infectious  diseases  are  caused  by 
bacilli,  for  example:  tuberculosis,  typhoid  fever,  and  diph- 


« 


■Qt, 


^^ 


*• 


„  /  ,'/    'T 


Fig.  35. — Showing  diplococci  Ijeiiig  taken  ui)  and  destroyed  by  phagocytes. 

(Abbott.) 


theria.    Suppuration  and  woinid  infection  are  usually  caused 
by  streptococci   or  staphylococci,   although  they  may   be 


INFECTION  AND  SUPPURATION  77 

caused  by  bacilli  or  diplococci.  Pneumonia  and  meninf^itis 
are  caused  by  diplococci. 

Each  variety  of  bacteria  is  again  divided  into  diflerent 
subdivisions.  Thus  we  have  tubercle  bacilli,  the  bacillus 
of  typhoid  fever,  the  diphtheria  bacillus,  the  tetanus  bacil- 
lus, the  streptococcus  of  erysipelas,  the  pneumococcus,  and 
the  meningococcus. 

Some  of  these  bacteria  are  specific,  that  is,  they  always 
cause  the  same  disease.  The  tubercle  bacillus,  when  it  causes 
disease,  always  causes  tuberculosis,  and  the  tetanus  bacillus 
always  causes  tetanus.  Abscess  formation  and  wound 
infection  is  usually  caused  by  one  of  the  various  forms  of 
cocci,  rarely  by  the  bacilli.  In  general,  infection  with 
streptococci  is  apt  to  be  more  severe  than  staphylococci 
infection. 

Asepsis  and  Antisepsis.^ — When  a  wound  or  object  is  free 
from  living  bacteria  it  is  said  to  be  aseptic  or  sterile.  Septic 
is  the  opposite  term  and  indicates  the  presence  of  infection. 
Objects  may  be  rendered  aseptic  by  heat  or  by  chemicals 
(disitifectants)  strong  enough  to  kill  all  living  organisms. 

When  a  thing  is  aseptic  it  is  said  to  be  "surgically  clean," 
which  is  somewhat  different  from  clean  in  the  ordinary  sense. 
Thus  you  may  take  a  rusty  needle  or  soiled  handkerchief  and 
boil  it  for  twenty  minutes  and  it  will  be  rendered  surgically 
clean,  although  apparently  little  changed,  while  the  white 
handkerchief  and  the  highly  polished  needle  that  has  been 
lying  on  the  table  for  several  days,  although  apparently 
clean,  may  be  covered  with  germs. 

An  antiseptic  is  a  substance  which  tends  to  prevent  infec- 
tion without  injuring  the  tissues.  Thus,  alcohol  can  be 
poured  on  the  hands,  killing  many  of  the  germs  without 
causing  serious  injury  to  the  hands. 

In  surgery,  articles  are  rendered  aseptic  or  sterile  by  one 
of  three  methods : 

1.  The  application  of  heat. 

2.  The  use  of  disinfectants. 

3.  The  use  of  antiseptics. 

Aseysis  by  Heat. — Heat  may  be  applied  by  the  open  flame, 
by  boiling,  or  by  superheated  steam.     The  open  flame  is 


78  WOUNDS   AXD    WnrXD    IXFECriON 

rarely  used  in  surgery,  l)ut  it  is  of  some  use  iu  first-aid  work. 
A  needle  or  knife-blade  held  in  a  fiame  until  it  is  too  hot 
to  touch  is  completely  sterilized,  or  aseptic.  This  process 
soon  destroys  the  steel  and  is  consequently  seldom   used. 

In  surgical  ])ractice,  boiling  is  the  method  connnonly  used 
to  disinfect  instruments.  Instruments,  rubber  goods,  and 
glassware  may  be  boiled  without  injury.  In  emergencies 
gauze  and  cotton  may  be  sterilized  by  boiling.  The  boiling 
should  be  contiiuied  for  at  least  fi^'e  minutes,  or,  better  still, 
twenty  to  thirty  minutes.  In  hospitals  and  surgical  sup- 
ply houses,  gauze,  cotton,  and  bandages  are  sterilized  by 
the  use  of  superheated  steam.  This  has  the  advantage  of 
leaving  the  material  dry  so  that  it  is  easily  handled.  Small 
packages  of  sterilized  material  may  be  A\Tapped  in  muslin 
or  in  paper  coverings  for  transportation.  These  coverings 
when  dry  are  not  penetrated  by  bacteria. 

Disinfectants.^ — Strong  acids  and  alkalies,  carbolic  acid 
(phenol),  solution  of  formalin,  and  many  other  substances 
in  strong  solutions  kill  all  bacteria,  serving  to  sterilize 
effectually  all  articles  wliich  are  introduced  therein. 

Instruments,  glassware  and  rubber  goods  may  be  sterilized 
by  this  method;  but,  owing  to  the  fact  that  disinfectants  are 
injurious  to  the  tissues,  the  excess  must  be  washed  off  with 
sterile  water  before  use.  For  this  reason  the  disinfectants 
have  a  limited  use  in  surgical  practice.  Their  use  is  largely 
confined  to  the  disinfection  of  infectious  excreta  and  for  the 
disinfection  of  waste  materials,  such  as  pus-soaked  gauze, 
blood-stained  cotton  and  the  like. 

Antiseptics. — These  are  substances  which  may  be  used  in 
milder  solutions  to  prevent  the  growth  and  destroy  bacteria, 
without  injury  to  the  body  tissues.  As  may  be  sujjposed 
they  are  less  eft'ective  than  disinfectants  but  they  are  suscep- 
tible to  broad  usage  and  in  many  places  where  disinfectants 
cannot  be  used.  The  most  frequently  used  antiseptics  are 
tincture  of  iodin  (one-half  strength) ,  alcohol  (one-half  to  full 
strength),  boric  acid  (saturated  solution),  hydrogen  perox- 
ide, weak  solution  of  carbolic  acid,  bichloride  of  mercury 
(1  to  1000)  and  many  others.  These  solutions  are  of  consid- 
erable value  in  surgery  because  of  their  convenience  and 


THE  REPAIR  OF  WOUNDS  79 

because  they  are  not  very  injurious  to  the  tissues.  Some 
antiseptics,  such  as  tincture  of  iodin,  may  be  used  freely  in 
some  parts  of  the  body,  but  are  not  suitable  for  application 
on  the  more  delicate  parts,  as  for  example,  about  the  eye. 
Instruments  and  glassware  may  be  soaked  for  several  hours  in 
carbolic  acid  solution  (5  per  cent.)  and  rendered  completely 
sterile. 

If  the  skin  is  painted  with  tincture  of  iodin,  an  incision 
may  be  made  and  if  care  is  taken  not  to  allow  infection  to 
enter  the  wound  subsequently  it  will  heal  without  suppura- 
tion. In  the  same  manner,  if  the  skin  is  cut  and  immediately 
painted  with  tincture  of  iodin  and  covered  with  a  dressing 
infection  will  not  take  place.  If  the  same  treatment  is 
given  with  alcohol  or  peroxide  of  hydrogen,  the  antiseptic 
action  is  also  obtained,  but  less  powerfully  than  with  tincture 
of  iodin. 

Surgical  Preparation  of  the  Hands. — Due  to  the  fact  that 
bacteria  are  always  present  on  the  surface  and  in  the 
pores  of  the  skin,  it  is  an  impossibility  to  render  the  hands 
surgically  clean.  For  this  reason^  surgeons  when  operating 
use  rubber  gloves  which  may  be  sterilized  by  boiling  or  by 
long  immersion  in  antiseptics. 

If  the  hands  are  well  scrubbed  with  soap  and  water  for 
five  minutes  or  longer  and  tests  are  made,  very  few  bac- 
teria will  be  found.  If  in  addition  they  are  immersed 
from  three  to  five  minutes  in  an  antiseptic  (bichloride  of 
mercury,  1  to  1000)  tests  will  show  almost  no  bacteria. 
They  are  almost  "surgically  clean"  and  should  be  so  prepared 
before  doing  a  surgical  operation  or  dressing  a  wound.  It  is 
important  to  remember  that  many  more  germs  are  ^emo^'ed 
by  the  use  of  soap  and  water  than  by  disinfectants  alone. 
So  that  in  an  emergency  treatment  it  is  far  better  to  wash 
the  hands  well  than  to  dip  them  in  antiseptic  solutions. 

THE   REPAIR   OF   WOUNDS. 

The  healing  of  wounds  and  the  necessary  measures  to 
produce  the  normal  return  of  function  are  more  in  the 
province  of  the  surgeon  than  in  that  of  the  first-aid  worker, 


SI) 


WOiXDiS   AXD    WOL.MJ   J\FL:cTU)X 


but  the  c'ni(.'riren(.'y  tiratiiicnt  is  hottt'r  uiulorstood  if  the 
first-aid  workt-r  lias  a  clear  c'()iicoi)tioii  of  tiic  i)rocoss  of 
lu'aliut;-. 

^MleIl  tho  wouiul  heals  without  iutVi'tiou  or  sujjpuratiou, 
it  is  said  to  heal  by  first  iutention.  The  surj^eon  briugs  the 
cut  cuds  of  the  tcudous  aud  skiu  iuto  ai)i)ositiou  by  sutures 
or  other  suitable  uiethods,  aud  the  suiall  crevice  betweeu 
the  incised  surfaces  fills  with  blood  clots  which  remain  asep- 
tic. \\'ithin  a  few  days  small  bloo(h-essels  grow  through 
these  thin  clots  and  enter  the  oi)posit.e  surface  of  the  wound. 


Fig.  36. — Swelling  and  inflanmiation  of  the  forearm  antl  hand  from  an 
infected  wound  of  the  hand.     (Ashhurst.) 


In  time  proliferation  of  the  cellular  elements  holds  the 
wound  edges  firmly  together,  and  healing  is  complete.  There 
is  little  or  no  discharge  from  such  a  wound. 

^Yhen  there  is  suppuration  or  M^hen  the  edges  of  the  woimd 
are  not  approximated,  the  \\'ound  heals  by  granulation.  In 
such  cases  the  wound  fills  from  the  bottom  and  the  edges, 
which  become  covered  with  a  soft  bright  red  cellular  tissue 
called  granulation  tissue.  The  slow  proliferation  of  this 
tissue  gradually  fills  the  wound  until  it  reaches  the  level  of 
the  skin.     The  skin  slowly  grows  inward  from  the  margin 


THE  REPAIR  OF  WOUNDS  81 

of  the  denuded  area,  finally  covering  the  surface   of  the 
wound. 

Primary  union,  or  healing  by  first  intention,  usually  takes 
place  in  about  a  week  and  the  union  is  firm  at  the  end  of  the 
second  week.  Compared  with  this,  healing  by  granulation 
is  very  slow.  Even  a  comparatively  small  wound  may  require 
several  weeks,  and  large  wounds  may  not  be  entirely  healed 
after  four  or  five  months. 


Fig.  37. — Infection  of  the  finger  from  a  neglected  wound.     This  should 
have  been  incised  several  days  before.     (Park.) 

Clinical  Course  of  Infected  Wounds. — When  a  wound  is 
infected  there  is  a  period  varying  from  a,  few  hom:'s  to  a 
few  days  during  which  it  is  to  all  appearances  aseptic.  This 
is  the  incubation  period  during  which  the  bacteria,  though 
present  and  active,  do  not  make  themselves  evident. 

Following  this  is  the  stage  of  reaction  when  the  wound 
becomes  painful  and  tender.  The  edges  are  reddened  and 
indurated  (hard).  The  presence  of  bacteria  causes  a  con- 
gestion in  the  region  of  the  wound.  The  white  cells  are 
thrown  out  as  a  protective  agency  to  destroy  the  bacteria, 
6 


82  WOUNDS  AND   WOUND  INFECTION 

and  in  cortain  sta,u:es  of  tlio  i)r()(rss  tlio  Avliitc  (vlls  may  he 
sorn,  niion)sc()])ically,  in  the  ])rcH'ess  of  clo\"ourin,u  tlio  bac- 
teria. The  mixture  of  sermn,  bacteria,  Avhite  blood  cells,  and 
partially  destroyed  tissue  cells  is  called  pus. 

If  the  pus  can  be  freely  discharged,  and  the  bac^teria  are 
not  powerful  enou<:;h  to  overcome  the  body  resistance,  heal- 
ing Avill  take  jilace.  But  if  the  discharge  is  confined  so  that 
it  cannot  escape  or  if  the  bacteria  are  especially  poisonous, 
the  area  increases  in  size,  and  cellulitis,  or  blood  poisoning, 
may  result.  This  is  shown  by  pain,  redness,  and  swelling  of 
the  part.     (Figs.  o()  and  37.) 

In  cases  in  which  the  discharge  is  free  and  the  infection 
is  subsiding,  healing  takes  place  from  the  bottom  and  the 
wound  gradually  fills  with  granulation  tissue  while  the  sup- 
puration still  continues.  After  a  week  or  ten  days  the 
suppuration  has  usually  to  a  huge  extent  subsided  and 
healing  by  granulation  proceeds  in  a  normal  manner. 

SUMMARY    OF    THE    TREATMENT    OF    WOUNDS. 

A.  Clean  Wounds. 

1.  Inspection  of  the  wound  to  determine  the  degree  of 
injury  and  the  amount  of  bleeding. 

2.  The  cleansing  of  the  hands  with  soap  and  water. 

If  there  is  time,  before  handling  the  wound,  the  hands 
should  be  rendered  surgically  clean  by  the  method  previously 
described. 

3.  The  sterilization  of  the  icoiind. 

(a)  If  the  wound  is  apparently  clean  it  should  be  painted 
with  tincture  of  iodin  (one-half  strength)  or  rinsed  with 
alcohol  (50  per  cent.).  The  iodin  should  be  swabbed  on  the 
cut  surface  as  well  as  upon  the  surrounding  skin. 

(b)  Wounds  showing  gross  contamination  with  dirt  and 
grime.  These  wounds  are  best  treated  })y  preliminary 
washing  with  soaj)  and  water  followed  by  thorough  rinsing 
with  clean  water.    Iodin  or  alcohol  may  then  be  applied. 

4.  The  Dressing. — Sterile  gauze  is  placed  over  the  wound 
so  as  to  stop  the  bleeding.  If  sterile  gauze  is  not  obtainable, 
a  clean  handkerchief  or  piece  of  linen  may  be  soaked  in  50 


SUMMARY  OF   TREATMENT  OF   WOUNDS  83 


Figs.  38  and  39. — Showing  the  appearance  of  a  badly  infected  hand  before 
treatment  and  the  same  hand  after  it  had  been  incised  by  the  surgeon. 
(Kanavel.) 


84  WOrXDS  AM)   WOUND  IXFECTION 

per  cent,  alcohol,  whisky,  or  other  antiseptic  sohition  and 
applied  wet  to  the  wound. 

5.  Bandaging. — A  bandage  is  applied  to  hold  the  dressing 
in  place.  If  hemorrhage  is  profuse,  several  compresses  and 
a  very  firm  bandage  may  be  necessary.  A  tournicpiet  is 
rarely  required  and  should  never  be  applied  until  other 
measures  fail.' 


Fig.  40. — Felon  of  the  thumb  which  has  opened  spontaneously.     Incision 
would  have  prevented  this  large  area  of  ulceration.     (Park.) 

B.  Infected  Wounds. — When  a  wound  shows  evidence  of 
infection  (increased  pain  of  a  throbbing  character,  swelling 
and  redness)  it  requires  treatment  at  once.  If  professional 
advice  is  not  available,  the  treatment  should  always  be 
directed  toward  securing  free  discharge.  The  dressing  should 
be  removed  at  once. 

This,  in  itself,  often  allows  the  discharge  which  has  been 
retained  by  the  adherent  dressing  to  escape.    A  continuous 

1  Owing  to  the  excessive  bleediuR  it  may  be  necessary  to  apply  a 
dressing  without  the  preliminary  care  of  the  hands  and  the  wound.  It  may 
be  necessary  to  pack  the  wound  cjuickly  with  the  available  material  at  hand. 
If  this  is  so,  secure  the  cleanest  material  possible.  A  clean  handkerchief  or 
towel  is  a  substitute  for  sterile  gauze  under  these  circumstances,  care  being 
taken  to  unfold  the  towel  or  handkerchief  so  that  an  absolutely  clean  spot 
is  brought  next  the  bleeding  surface.  After  such  a  dressing  has  been 
applied  the  wound  recjuires  expert  care  as  soon  as  possible. 


SUMMARY  OF   TREATMENT  OF   WOUNDS  85 

wet  dressing?  is  then  applied,  usinfi;  preferably  a  saturated 
solution  of  borie  acid  to  keep  the  dressing  constantly  wet. 
If  boric  acid  is  not  available,  10  per  cent,  alcohol  or  witch- 
hazel  may  be  used.  The  essential  point  is  to  keep  the  dress- 
ing wet  so  that  drainage  may  be  free,  and  this  may  be  done 


Fig.  41. — Inflammation  about  the  finger-nail  as  the  result  of  an  infected 
"hang-nail."     (Kanavei.) 

with  ordinary  tap  water  if  no  antiseptics  are  at  hand.  Car- 
bolic acid  is  nemr  used  as  a  wet  dressing,  because  it  may 
cause  gangrene. 

Clean  wounds  if  not  deep  or  extensive  may  not  require 
the  services  of  a  physician;  infected  wounds  always  need 
professional  care.  Whenever  pus  is  present  beneath  the  skin, 
or  elsewhere  in  the  body,  an  incision  is  required  at  the  earliest 
opportunity.  Figs.  37  and  38  represent  an  advanced  stage  of 
suppuration  which  should  have  been  treated  by  incision  before 
becoming  so  pronounced. 


CHAPTER  IV. 

BANDAGING. 

A  BANDACK  is  a  Strip  of  cloth,  usually  muslin  or  ji;auze, 
which  is  ai)i)lie(l  to  the  body  to  hold  a  dressing  in  place,  to 
secure  splints,  or  to  protect  and  support  any  part  of  the 
body.  In  physicians'  offices  and  in  hospitals  the  roller  ban- 
dage is  used  almost  exclusively,  but,  in  emergency  work, 
the  triangular  bandage  is  often  more  easily  secured  and 
applied.  If  neither  form  is  obtainable  a  handkerchief  or 
torn  strips  of  clean  cotton  or  linen  cloth  may  be  used.  As 
the  bandage  material  does  not  come  in  contact  with  the 
wound  it  is  not  necessary  that  it  be  sterilized.  However,  a 
sterile  bandage  is  an  additional  precaution  against  infection, 
and  most  of  the  bandages  prepared  by  the  surgical  supply 
houses  are  sold  in  sterile  packages  ready  for  use. 

THE    TRIANGULAR   BANDAGE. 

This  bandage,  often  called  Esmarch's  triangidar  bandage, 
is  made  from  any  suitable  material,  preferably  unbleached 
muslin,  by  cutting  a  piece  about  a  yard  square  diagonally 
from  corner  to  corner,  forming  two  triangular  bandages. 
The  result  is  a  triangular  piece  of  cloth  with  one  long 
margin,  the  base,  and  two  shorter  margins,  the  sides.  The 
corner  opposite  the  lower  border,  or  base,  is  called  the  apex 
or  point  of  the  bandage.  The  two  other  corners  are  termed 
the  ends.  The  bandage  may  be  made  from  any  suitable 
material,  and  may  vary  in  size,  but  for  satisfactory  work 
the  base  should  be  at  least  40  inches  in  length. 

To  fold  the  bandage,  when  not  in  use,  the  two  ends  are 
brought  together,  thus  folding  it  perpendicularly  down  the 
center,'  then  the  ends  and  point  are  folded  over  to  the  base 

'  When  folded  in  this  manner,  the  bandage  forms  a  triangle,  half  the  size 
of  the  original.  It  may  be  conveniently  used  in  this  smaller  size  in  some 
locations. 


THE   TRIANGULAR  BANDAGE  87 

of  the  perpendicular,  thus  forming  a  square,  which  is  again 
folded  through  the  center.  The  rectangle  thus  formed  is 
folded,  forming  a  square,  and  again  folded,  forming  a  rectan- 
gular packet  about  six  inches  in  length,  which  easily  fits  into 
the  pocket. 

For  use,  the  bandage  may  be  used  open  or  folded,  either 
broad  or  narrow.  In  folding  for  use,  the  bandage  is  spread 
out  with  the  base  toward  you  and  the  point  is  brought  down 
to  the  middle  of  the  lower  border.  Then  fold  it  toward  you, 
once  for  the  broad  bandage,  two  or  three  times  for  the  nar- 
row bandage.  The  bandage  is  never  placed  directly  in  con- 
tact with  the  wound,  but  only  after  the  sterile  dressing  has 
been  applied.  The  method  of  application  of  this  bandage 
for  the  various  regions  of  the  body  is  as  follows:^ 


Fig.  42. — The  triangular  bandage.     (Wharton.) 

Wounds  of  the  Scalp. — Lay  the  middle  of  the  bandage  on 
the  head  so  that  the  lower  side  lies  crosswise  over  the  fore- 
head, the  point  hanging  down  over  the  nape  of  the  neck. 
Carry  the  two  ends  backward  over  the  ears,  cross  them  at 
the  back  of  the  head,  bring  them  forward  and  tie  them  on 
the  forehead.  Then  stretch  the  point  forward,  turn  it  over 
the  back  of  the  head  and  fasten  it  with  a  pin. 

Wounds  of  the  Forehead. — Fold  the  bandage  narrow,  lay 
its  center  over  the  wound,  and,  carrying  the  ends  backward 
tie  them  at  the  opposite  side  of  the  head,  or,  if  the  bandage 
be  long  enough,  the  ends  may  be  crossed  at  the  back  of  the 
head,  carried  forward  and  tied  in  front. 

'  Instructions  for  Using  the  Triangular  Bandage.  Published  by  the  Society 
for  Instruction  in  First  Aid  to  the  Injured,  New  York  City. 


ss 


BANDAGING 


Wounds  of  the  Chest. — I'hice  the  middle  of  tlie  bandage  on 
the  chest  with  the  ])oint  over  one  shonlder,  carry  the  two 
ends  around  the  chest  and  tie  at  the  hack;  next  (h-aw  the 
point  o^•er  the  shoulder  downward  and  tie  or  pin  it  to  one  of 
the  ends. 

Wounds  of  the  Hip. — Fold  a  bandage  narrow  and  tie  it 
around  the  body  for  a  waist  belt.  Lay  the  center  of  a  second 
bandage  on  the  wound,  with  the  ])oint 
upward,  pass  the  ends  around  the 
upper  part  of  the  thigh,  cross  and  carry 
to  the  front,  and  knot  them  together. 
Next  pass  the  point  imder  the  waist 
belt  and  fasten  it  with  a  i)in. 

Wounds  of  the  Upper  Arm. — Place  the 
center  of  a  l)road-folded  bandage  on 
the  front  of  the  limb,  carry  the  ends 
around  to  the  opposite  side,  cross  them, 
bring  them  back,  and  knot  them  together. 
Next  take  a  broad-folded  bandage,  throw 
one  end  over  the  shoulder  on  the  woimded 
side,  carry  it  round  the  neck  so  as  to 
be  visible  at  the  opposite  side;  then 
bend  the  arm  carefully  and  carry  the 
wrist  across  the  middle  of  the  bandage 
hanging  down  in  front  of  the  chest. 
This  done  take  the  lower  end  over  the 
shoulder  on  the  sound  side  and  tie  the 
two  ends  together  at  the  nape  of  the 
neck.  This  second  bandage  forms  a  sling 
for  the  arm. 

Wounds  of  the  Forearm,  with  Broad  Sling 

for  Arm. — Bandage  the  wound  as  above. 

Then    take    a    second    bandage,  throw 

one  end  over  the  shoulder  on  the  sound 

side,  and  carry  it  round  the  back  of  the 

neck  so  as  to  be  visible  at  the  opposite 

side,  where  it  is  to  be  held  fast;  place  the  point  behind  the 

elbow  of  the  injured  arm  and  draw  down  the  end  in  front 

of  the  patient.    Next,  bend  the  arm  carefully  and  place  it 


Fig.  43.  —  Diagram 
illustrating  var  i  o  u  s 
ways  of  applying  the 
triangular  bandage. 


THE  FOUR-TAILED  liANDAflE  89 

across  the  chest  in  the  middle  of  the  cloth.  Then  take  the 
lower  end  upward  over  the  shoulder  on  the  wounded  side 
and  knot  to  the  other  end  at  the  nape  of  the  neck.  This 
done,  draw  the  point  forward  round  the  elbow  and  fasten  it 
with  a  pin. 

Wounds  of  the  Hand. — Take  a  bandaji;e,  spread  it  out,  and 
lay  the  wrist  on  the  lower  border  with  the  fingers  toward  the 
point.  Next  turn  the  point  over  the  fingers  and  carry  it 
up  on  the  wrist.  This  done,  carry  the  ends  round  the  wrist, 
fixing  the  point,  carry  them  back  again  and  knot  together. 

Wounds  of  the  Thigh,  Knee  or  Leg. — Bandage  in  the  same 
manner  as  was  directed  for  wounds  of  the  upper  extremity. 
Usually  a  single  bandage  is  all  that  is  required. 

Wounds  of  the  Foot. — ^Take  a  bandage,  spread  it  out  and 
place  the  sole  of  the  foot  in  its  center,  with  the  toes  in  the 
direction  of  the  point.  Draw  the  point  upward  over  the 
toes  and  the  instep  of  the  foot;  then  take  the  ends  forward 
round  the  ankle,  across  the  instep,  carry  them  downward 
and  knot  them  together  on  the  sole  of  the  foot,  or,  if  the 
bandage  be  long  enough,  cross  them,  bring  them  forward 
again,  and  knot  on  instep. 

To  Secure  Splints. — Ordinary  or  improvised  splints  may  be 
applied  to  the  broken  limb,  and  held  in  position  by  taking 
two  triangular  bandages,  folded  broad  or  narrow  according 
to  circumstances,  and  tieing  them  securely,  one  above  and 
the  other  below  the  fracture. 

To  Improvise  a  Tourniquet. — Fold  the  triangular  bandage 
narrow  and  tie  it  about  the  limb  over  a  firm  pad  above  the 
course  of  the  main  artery;  then  insert  a  stick  under  the  ban- 
dage and  twist  it  until  such  pressure  is  brought  to  bear  upon 
the  artery  that  the  circulation  of  the  blood  through  it  is 
stopped. 

THE   FOUR-TAILED   BANDAGE. 

This  is  made  from  a  strong  piece  of  cloth  about  a  yard 
long  and  five  or  six  inches  in  width.  The  ends  are  split  down 
the  middle  to  a  point  three  or  four  inches  from  the  center. 
It  is  particularly  applicable  to  wounds  about  the  head  and 
face. 


90  BANDAGING 

Wounds  of  the  Scalp.- — The  conter  of  the  l^iuidage  is  placed 
()\('r  x\\v  (Iri-ssiiig  and  the  end  allowed  to  hang  down  on  both 
sides.  The  two  front  ends  are  then  drawn  back  and  pinned 
at  the  back  of  the  neck  and  the  two  back  ends  are  drawn 
forward  and  fastened  beneath  the  chin.  If  the  dressing  is 
on  the  back  of  the  head  the  ends  are  crosst^i  and  fastened 
under  the  chin  and  over  the  forehead. 


Hp 

3 

Fig.  44. — Four-tailed  bandage  of  the  chin.     (Wharton.) 

Wounds  of  the  Chin.  (Applicable  also  to  fracture  of  the  lower 
jaw.) — The  bandage  should  be  narrower  than  that  described 
above,  about  three  inches  in  width,  and  the  slits  should  be 
extended  nearer  to  the  center  of  the  bandage.  After  the 
dressing  has  lieen  applied  (or  without  a  dressing  in  the  case 
of  fracture)  the  center  of  the  bandage  is  placed  over  the  point 
of  the  chin  and  the  lower  tails  are  carried  upward  and 
fastened  over  the  top  of  the  head.  The  upper  tails  are  then 
fastened  back  of  the  neck. 

THE   ROLLER   BANDAGE. 

The  roller  bandage  is  made  by  tearing  strips  of  muslin 
or  gauze  about  fi^•e  yards  long,  and  three  or  four  inches  in 
width.     These   are   rolled   either   with   the  fingers,   or  by 


THE  ROLLER  BANDAGE 


91 


machine,  into  a  closely  wound  roll.  When  narrower  ban- 
dages are  required  the  roll  may  be  cut,  transversely,  with 
a  sharp  knife  into  the  desired  width. 

To  Roll  a  Bandage.— In  rolling  a  bandage  it  is  necessary 
to  make  the  first  turns  very  tight,  or  a  loose  bandage,  which 
is  very  diflncult  to  apply,  will  result.  The  roll  is  started  by 
folding  the  end  of  the  bandage  tightly  upon  itself  until  a 
small  firm  roll  is  formed.  This  is  held  by  the  ends  between 
the  thumb  and  index  finger  of  the  left  hand.  The  loose  end 
of  the  bandage  passes  between  the  thumb  and  index  finger 
of  the  right  hand.    The  roll  is  grasped  in  the  palm  of  the 


Fig.  45. — Method  of  rolling  a  bandage  by  hand.     (Wharton.) 


right  hand  and  by  a  rotary  movement  of  the  right  -^-rist 
combined  with  the  alternate  holding  and  loosening  of  the 
left  hand,  the  roll  can  be  completed.  With  a  little  practice 
a  tightly  wound  roll  may  be  obtained. 

Machine-rolled  bandages  are  more  satisfactory  for  use. 
They  may  be  rolled  with  a  hand  machine,  or  may  be  pur- 
chased ready  for  use. 

Application  of  a  Bandage. — A  few  inches  of  the  bandage  is 
unrolled  and  the  loose  end  taken  in  the  left  hand  while  the 
roll  is  held  in  the  right.  The  outer  side  of  the  bandage  is 
then  placed  next  to  the  dressing  and  the  bandage  carried 


V    02 


BANDAGING 


around  the  part  to  ho  drosscxl,  making  a  single  turn,  wliich 
anchors  the  hanclage.  The  simplest  form  of  bandage,  the 
circular  handngc,  is  a])])lical)lc  to  ])(trti()ns  of  the  body  and 


Fig.  46. — BandaKO  wimlcr.     (Wharton.) 

-extremities  where  the  size  remains  the  same.  In  this  case 
the  bandage  is  carried  around  and  around  the  part  in  a 
spiral  until  the  dressing  is  entirely  covered.  ^Vhc^  this  is 
done  the  end  is  cut  and  secured  either  by  a  pin  or  by  tearing 


%^ 


m 


Fig.  47. — Roller  bandage.     (Wharton.) 


the  bandage  into  two  tails,  one  of  which  is  passed  backward 
about  the  limb  and  tied  to  the  other  end  on  the  opposite 
side. 


THE  ROLLER  BANDAGE 


93 


Figure-of-eight  Bandage. —  In  haiidagiiif^  an  arm  or  leg  it  is 
found  that  a- simple  eircular  bandage  does  not  fit  snugly. 
There  is  a  fulness  of  one  edge  at  some  point.  In  order  to 
overcome  this  the  direction  of  the  bandage  is  altered  until 
both  edges  fit  snugly.  This  means  that  the  bandage  must 
be  turned  sharply  upward  and  carried  around  the  limb 
several  inches  above  the  previous  turn.  It  is  now  brought 
downward  and  forward  over  the  upward  turn,  crossing  it  and 
forming  a  figure-of-eight.  This  process  is  repeated,  over- 
lapping each  turn  slightly,  so  as  to  cover  in  the  entire  part. 


Fig.  48. — Figure-of-eight  bandage  of  the  leg.     (Wharton.) 


The  slack  or  fulness  is  located  at  the  back  of  the  upper  turn, 
where  it  will  be  covered  with  subsec^uent  turns.  Care  should 
be  taken  in  any  bandage  to  have  it  applied  firmly,  but  never 
tight  enough  to  act  as  a  hindrance  to  the  circulation. 

Spiral  Reverse  Bandage  of  the  Forearm. — Another  method 
of  taking  in  the  slack  which  occurs  along  one  side  of  a  ban- 
dage applied  to  a  part  of  the  body  which  shows  variation  in 
size  and  shape  is  the  spiral  reverse.  On  the  arms  and  legs, 
which  are  roughly  cone-shaped,  the  lower  edge  of  the  circu- 
lar bandage  is  always  loose,  especially  in  stout  persons. 
Unless  the  spiral  reverse  or  the  figm-e-of-eight  is  applied, 


94 


BAXDAdlXa 


t\\v  bandatic  will  \)v  uik'ncmi  in  appearance  and  easily  disar- 
ranged. 

In  making  a  spiral  re\erse  of  the  forearm  the  bandage  is 
first  fixed  by  two  eirenlar  turns  about  the  wrist.  Tlu>  third 
turn  is  made  to  run  up  the  forearm  so  that  both  edges  of  the 
strip  lie  smoothly  on  the  forearm.  The  right  hand  holds 
the  bandage  taut  and  the  left  thumb  is  placed  ui)on  the 
lower  margin  of  the  bandage  at  a  ])oiut  corresponding  to  the 
median  line  of  the  forearm.  The  right  hand  is  now  allowed 
to  relax  and  the  bandage,  turned  toward  the  operator 
through  an  angle  of  ISO  degrees,  is  passed  around  the  limb 
and  again  drawn  taut.     There  is  now  a  rcA'erse  of  the  ban- 


r  iG.  49. — Spiral  reversed  bandage  of  the  upper  cxtreiuit>'.     (Wharton.) 


dage  at  one  point,  and  the  next  turn  may  be  made  smoothly 
about  the  forearm  overlai)ping  the  preceding  turn  about 
one-half.  Each  time  the  bandage  reaches  the  front  of  the 
arm  a  reverse  is  made.  Near  the  elbow  where  the  forearm 
grows  smaller  the  reverse  may  be  discontinued  and  the 
bandaging  continued  by  the  use  of  circular  turns. 

If  this  bandage  is  correctly  applied  the  forearm  will  be 
smoothly  coverefl  and  the  reverses  lie  in  a  straight  row  down 
the  front  of  the  forearm. 

The  spiral  reverse  may  be  applied  in  the  same  manner  to 
the  arm,  leg,  or  thigh. 

Spica  of  the  Shoulder.- T he  term  si)ica  is  generally  used  to 
denote  a  bandage  which  includes  a  part  of  the  extremity 


rflE   ROLLER   BAND  AGE  95 

and  a  part  of  the  trunk.  The  spica  of  the  shoulder  begins 
by  two  or  three  circular  turns  about  the  upper  part  of  the 
arm  on  the  affected  side.  The  l)andage  is  then  carried  a  little 
upward  and  across  the  shoulder,  obliquely  downward  across 
the  back,  under  the  armpit  of  the  opposite  side,  and  upward 
across  the  chest  to  the  afiected  shoulder,  and  finally  around 
the  arm.  The  next  turn  follows  the  first,  overlapping  about 
one-half  at  the  shoulder,  but  exactly  coinciding  beneath  the 
opposite  armpit.  When  completed  the  shoulder  will  be 
covered. 


Fig.  50. — Spica  of  the  shoulder.     (Wharton.) 

Spica  of  the  Groin. — Two  circular  turns  are  taken  about 
the  upper  part  of  the  thigh  and  the  bandage  is  then  carried 
obliquely  upward  to  the  waist  line,  crossing  the  thigh  from 
within  outward.  It  is  then  carried  once  and  a  half  about 
the  waist  to  the  front  of  the  abdomen,  from  whence  it  is 
directed  obliquely  downward,  crossing  the  first  oblique  turn 
on  the  front  of  the  affected  thigh  and  finally  covering  the 
first  turn  made  around  the  thigh.  The  turns  are  repeated 
until  the  groin  is  entirely  covered. 

Spica  of  the  Buttock. — The  operator  stands  behind  the 
patient  and  begins  the  bandage  by  two  turns  about  the 
upper  part  of  the  thigh,  the  turns  being  made  from  within 


90 


BANDAGING 


outward,  as  in  thr  pircoding  ])aii{la<2:o.  For  the  left  buttock 
the  l)an(laj;e  is  carried  ol)li(juely  upward  across  the  left  thij:;h 
to  the  waist  line  on  the  left  side,  then  around  the  abdomen 

to  the  right  side,  making  a  full 
circular  tm'u  about  the  waist  to 
the  back.  From  this  ])oint  the 
bandage  inclines  downward  to 
the  left  thigh,  crossing  the  first 
ob]i(]ue  turno\er  the  left  })uttock 
and  tlu'n  making  a  single  turn 
around  the  thigh.  This  process 
is  continued  by  overlapping  the 
()})lique  turns  until  the  buttock 
is  (>ntirely  covered.  For  the  right 
buttock  the  turns  are  the  same, 
but  run  in  the  reverse  direction. 

The  Spica  of  Both  Groins. — 
Ihis  bandage  is  begun  by  a 
circular  turn  about  the  waist  and 
carried  on  to  the  left  thigh  in  an 
oblique  direction.  After  a  circular 
turn  about  the  thigh  the  bandage 
is  carried  obliquely  back  to  the 
waist  and  a  circular  turn  made.  It  is  next  passed  obli(|uely 
to  the  right  thigh.  These  turns  are  alternated  until  both 
groins  are  covered.  The  buttocks  may  be  covered  in  the 
same  manner  by  making  the  points  of  crossing  behind. 

Figure-of-eight  of  the  Elbow. — ^This  should  always  be 
applied  when  the  elbow  is  partially  l)ent.  Otherwise  it  will 
prove  too  tight  and  most  uncomfortable.  The  bandage 
begins  by  a  circular  turn  about  the  upper  part  of  the  fore- 
arm and  is  carried  obliquely  across  the  bend  of-  the  elbow 
to  the  lower  part  of  the  arm,  where  a  complete  turn  is  made. 
The  next  turn  brings  the  bandage  obliquely  down  across  the 
bend  of  the  elbow  to  the  forearm,  where  it  encircles  the 
forearm  a  little  higher  than  the  previous  turn.  The  figure- 
of-eight  is  then  continued,  overlapping  the  turns  until  the 
point  of  the  elbow  is  covered. 

The  bandage  may  be  applied  in  the  reverse  direction,  that 


Fig.  51. — Spica  of  the  buttocks. 
(Wharton.) 


THE  ROLLER  BANDAGE 


97 


is,  beginning  at  the  point  of  the  elbow.  Two  circular  turns 
pass  around  to  the  elbow  at  this  point;  the  third  turn  is 
now  carried  a  little  above  the  first  two  turns  at  the  outer 
side  and  the  fourth  turn  a  little  below  them;  all  the  turns 
coinciding  at  the  bend  of  the  elbow.  In  this  manner  a  figure- 
of-eight  is  developed  which  soon  covers  the  entire  region  of 
the  elbow.  The  bandage  is  fixed  by  a  circular  turn  about 
the  forearm. 


Fig.  52. — Figure-of-eight  bandage  of  the  elbow.     (Wharton.) 


Figure-of-eight  of  the  Knee.^ — ^This  corresponds  exactly  to 
the  figure-of-eight  of  the  elbow. 

Finger-tip  Bandage. — This  is  begun  by  two  turns  of  a  nar- 
row bandage  about  the  wrist.  The  third  turn  is  brought 
down  obliquely  across  the  back  of  the  hand  to  the  affected 
finger,  where  it  is  passed  once  or  twice  around  the  finger 
to  fix  it  firmly  in  place.  It  is  turned  on  itself  at  a  right 
angle  and  held  by  the  finger  of  the  left  hand  while  the  right 
hand  draws  the  bandage  downward  over  the  tip  of  the 
7 


98 


BAXDAGING 


finger  to  tlie  front  of  this  finyor.    The  direction  is  elinnijed, 
the  fold  l)eiiiu-  held  hv  the  thnnih  of  the  left  hand  and  the 


Fig.  53. — Figurc-of-cight  bandage  of  the  knee.     (Wharton.) 


Fig.  54.— Spiral  bandage  of  the  finger.     (Wharton.) 

bandage  brought  back  to  the  back  of  the  finger  where  it  is 
held  with  the  left  forefinger.     This  is  repeated  until  there 


THE  ROLLER  BANDAGE 


99 


are  several  turns  over  the  tip  of  the  finger.  Holding  these 
folds  in  place,  the  direction  of  the  bandage  is  again  changed 
and  a  circular  turn  made  about  the  end  of  the  finger  over 
the  loose  folds  which  cover  the  tip.  The  bandage  is  then 
carried  up  the  finger,  either  by  circular  turns  or  by  a  spiral 
reverse,  to  the  base  of  the  finger,  from  whence  it  is  carried 
across  the  back  of  the  hand  to  the  wrist,  where  it  is  fixed. 
If  more  than  one  finger  requires  bandaging,  the  same  bandage 
may  be  used  by  passing  obliquely  to  the  second  finger  after 
completing  the  first  bandage  at  the  wrist. 


Fig.  55. — Gauntlet  bandage. 
(Wharton.) 


Fig.  56.- 


-Demigauntlet  bandage. 
(Wharton.) 


Gauntlet  Bandage. — This  is  similar  to  the  preceding  except 
that  the  tips  of  the  fingers  are  not  necessarily  covered.  The 
bandage  passes  from  the  wrist  to  the  finger  and  spirally 
around  the  finger  to  the  tip.  No  attempt  is  made  with  these 
first  turns  to  cover  the  entire  finger.  A  circular  turn  is  then 
made  about  the  end  of  the  finger  and  the  bandage  continued 
to  the  base  either  by  a  figure-of-eight  or  a  spiral  reverse. 
From  the  base  of  the  finger  the  bandage  goes  back  to  the 
wrist  and  then  to  a  second  finger  until  all  the  fingers  are 


100 


BANDAGING 


covered.  It  will  now  be  found  that  the  entire  back  of  the 
hand  is  covered,  but  the  palm  is  left  free. 

In  the  demigauntht  the  bandage  is  the  same,  except  that 
the  fingers  are  not  bandaged.  The  turn  around  the  wrist  is 
made  a  nil  brought  down  to  the  base  of  the  finger,  a  single 
turn  being  made,  and  the  bandage  then  brought  back  to 
the  wrist.  The  bandage  is  carried  to  the  other  fingers  in  the 
same  manner,  the  result  being  that  the  back  of  the  hand  is 
covered  but  the  palm  and  fingers  are  left  free. 

A  reverse  gauniJei  is  a  similar  bandage  so  applied  as  to 
cover  the  palm  ^^'hile  the  back  of  the  hand  is  left  free. 


Fig.  57. — Bandage  of  the  foot,  not  covering  the  heel.      (Wharton.) 


Figure-of-eight  of  Ankle  and  Foot. — It  begins  by  a  circular 
turn  about  the  ankle  and  then  passes  obliquely  downward 
to  the  base  of  the  toes  where  a  single  turn  passes  around  the 
foot.  It  then  runs  oblicjuely  across  the  ui)per  surface  of  the 
foot  to  the  side  of  the  foot  where  it  parallels  the  sole  to  the 
back  of  the  heel,  then,  running  around  the  heel  it  passes 
forward  parallel  to  the  outer  edge  of  the  sole  to  about  the 
midi)art  of  the  foot.  From  this  point  it  passes  obliquely  over 
the  foot,  crossing  the  previous  oblique  turn.  In  this  bandage 
the  lower  margin  is  made  firm  while  the  upper  margin  is 
left  slack  to  be  covered  by  the  second  turn  of  the  figure-of- 
eight.  As  the  bandage  is  continued  the  third  or  fourth 
turn  falls  naturally  around  the  ankle  where  the  bandage  is 
fixed.    This  bandage  does  not  cover  the  point  of  the  heel. 


THE  ROLLER  BANDAGE  101 

Figure-of-eight  of  the  Heel.  1  his  bandage  begins  with  a 
circular  turn  directly  around  the  heel  and  instep.  The  next 
turn  coincides  with  the  first  at  the  instep  but  overlaps  slightly 
below  the  heel.  This  is  followed  by  another  turn  whicrh  over- 
laps slightly  above  the  heel,  thus  forming  a  figure-of-eight. 
These  turns  are  repeated  until  the  entire  heel  is  covered. 
The  bandage  may  be  completed  by  circular  turns  about  the 
foot  or  ankle,  as  required,  or  it  may  be  continued  up  the  leg. 


Fig.  58. — Recurrent  bandage.     (Wharton.) 

Recurrent  Bandage  of  the  Toes. — The  toes  are  seldom  ban- 
daged separately  as  are  the  fingers.  After  the  dressing  is 
applied,  the  bandage  is  started  on  the  upper  surface  of  the 
foot  and  held  in  place  by  the  fingers  of  the  left  hand.  It 
passes  directly  downward  over  the  toes  and  onto  the  sole 
of  the  foot.  About  two  inches  from  the  toes  it  is  held  by  the 
left  thumb  and  turned  directly  backward  over  the  toes  to 
the  upper  surface  of  the  foot,  This  process  is  repeated  until 
the  toes  are  all  covered  and  the  ends  of  the  recurrent  strips 
are  held  in  place  by  a  few  circular  turns  about  the  foot. 

Recurrent  Bandage  of  the  Slump. — An  amputation  stump 
may  require  bandaging.  This  is  accomplished  in  exactly  the 
same  manner  as  the  recurrent  bandage  of  the  toes. 

Figure-of-eight  of  the  Leg. — A  circular  turn  is  made  about 
the  ankle  and  the  bandage  carried  upward  by  spiral  turns 


102 


BAXDAGING 


until  the  increasing?  si^e  of  the  leji  causes  tlie  lower  niar{j;in 
of  the  bandajie  to  become  slack.  This  usually  occurs  after 
about  three  turns.  The  bandage  is  then  inclined  oblicjuely 
upward  to  above  the  calf  and  a  circular  turn  is  made  about 
the  leg  at  this  point.  Tlie  next  turn  is  inclined  obliciuely 
downward,  crossing  the  upward  turn  obli(|uely,  and  another 
circular  turn  is  made  about  the  ankle  just  above  the  previous 
circular  turns.  The  bandage  is  then  carried  upward,  over- 
lapping the  upward  turn  and  again  passed  around  the  leg 
just  above  the  calf.  These  turns  are  all  repeated  until  the 
leg  is  covered.  After  the  first  few  figures-of-eight  the  cir- 
cular turns  may  be  omitted.  If  there  is  much  tendency  to 
swelling  of  the  foot,  this  bandage  should  be  combined  with 
the  figure-of-eight  of  the  foot  and  ankle. 


Fig.  59. — Recurrent  bandage  of  an  amputated  stump  covered  with  a  spira 
reverse  extending  up  the  hmb.     (Wharton.) 

Eye  Bandage. — For  the  right  eye.  A  one  and  a  half-inch 
bandage  is  fixed  by  two  circular  turns  about  the  head  abo\'e 
the  ears,  running  from  right  to  left  in  front.  The  third  turn 
is  carried  downward  at  the  back  of  the  head  below  the  right 
ear,  and  then  upward,  covering  the  right  eye.  The  left  eye 
is  bandaged  in  the  same  manner,  excepting  that  the  bandage 
is  reversed,  beginning  from  left  to  right.  For  both  eyes  the 
first  three  turns  are  put  on  as  above  and  the  fourth  turn  is 
continued  around  the  head.  When  this  turn  reaches  the 
front  of  the  head  the  bandage  is  carried  downward  from 


THE  ROLLER  BANDAGE 


103 


right  to  left  over  the  left  eye,  below  the  left  ear  aiifl  finally 
upward  to  join  the  circular  turns.  A  single  turn  is  com- 
pleted bringing  the  bandage  to  the  back  of  the  head  from 
whence  it  is  carried  downward  below  the  right  ear,  over  the 
right  eye  and  back  to  the  forehead.  The  turns  continue 
alternately  until  both  eyes  are  covered. 


Fig.  60. — Bandage  of  the  right  eye. 

(Wharton.) 


Fig.  61. — Bandage  of  both  eyes. 
(Wharton.) 


Ear  Bandage. — The  ears  may  be  covered  in  exactly  the 
same  manner  as  the  eyes  except  that  the  turns  are  made  to 
overlap  at  the  region  of  the  ear  instead  of  at  the  eye. 

Head  Bandage. — The  back  of  the  head  may  be  bandaged 
with  a  two-inch  bandage  fixed  by  two  circular  turns  around 
the  head  above  the  ears.  The  third  turn  covers  the  first 
turns  in  front,  but  behind,  it  is  carried  about  one-half  inch 
below  the  previous  turns.  The  fourth  turn  again  covers  the 
previous  turns  in  front,  but  is  carried  upward  about  one- 
half  inch  behind.  By  continuing  these  turns,  keeping  the 
bandage  a  single  width  in  front  and  alternating  the  turns, 
first  below  and  then  above  at  the  back  of  the  head,  a  large 
area  may  be  successfully  bandaged. 

If  this  process  is  reversed  and  the  circular  turns  made  to 
overlap  behind,  the  forehead  may  be  covered  by  making 
each  turn  a  little  higher  in  front  than  the  previous  turn. 


104 


BANDAGING 


The  top  of  the  head  cannot  be  covered  by  either  of  these 
banchiges.  This  portion  of  the  scalp  may  be  covered  by  a 
bandage  which  starts  at  the  top  of  the  head  and  is  carried 
chrecth'  downward,  behind  the  left  ear,  under  the  chin  and 
upward  in  front  of  the  right  ear  to  the  starting-point.  The 
second  turn  is  carried  downward,  coN'ering  the  first  turn 
behind  the  left  ear,  then  under  the  chin  and  upward,  this 
time  behind  the  right  ear.  The  third  turn  passes  around  the 
head  in  the  same  manner,  this  time  in  front  of  both  ears. 
There  are  thus  three  distinct  turns;  one  passes  behind  the 


Fig.  62. — Bandage  adapted  to  wounds  of  the  back  of  the  head,  or  of  tlie 
forehead.     (Wharton.) 


left  ear  and  in  front  of  the  right;  the  next  passes  behind  both 
ears;  and  a  third  passes  in  front  of  both  ears.  The  alter- 
nating turns  in  front  of,  and  behind  the  ears  hold  the  bandage 
firmly  fixed.  This  bandage  may  also  be  adapted  to  the 
treatment  of  wounds  of  the  face. 

Recurrent  Bandage  of  the  Head. — For  this  bandage  a  two- 
inch  roller  is  used.  The  bandage  is  started  on  the  forehead 
and  carried  in  the  midline  over  the  top  of  the  head  to  the 
nape  of  the  neck.  It  is  turned  upon  itself  and  brought  back 
to  the  starting-point,  the  second  strip  l)cing  carried  slightly 
to  one  side.    On  reaching  the  starting-point  the   bandage  is 


THE  ROLLER  BANDAGE  105 

again  reversed  and  carried  backward,  ()\'crlai>piiig  about 
one  inch  to  the  other  side.  When  this  tliird  fold  of  the 
bandage  reaches  the  nape  of  the  neck  it  is  again  folded  upon 
itself  and  brought  back  to  the  forehead  overlapi)ing  the 
second  fold.  If  this  process  is  repeated  the  entire  scalp  will 
be  covered  with  overlapping  folds  running  backward  and 
forward.  With  the  last  fold  the  bandage  is  turned  on  itself 
so  as  to  make  a  circular  fold  about  the  head  above  the  ears, 
which  holds  the  end  of  the  recurrent  folds  firmly  in  place. 
As  will  be  noticed  the  bandage  over  the  scalp  is  very  loose 
and  incapable  of  exerting  the  slightest  pressure. 


Fig.  63. — Recurrent  bandage  of  the  head.     (Wharton.) 

Circular  Bandage  of  the  Neck. — A  dressing  of  the  neck 
may  be  held  in  place  by  a  simple  circular  bandage.  It  is 
very  important  not  to  exert  pressure  in  bandaging  the  neck. 
The  bandage  should  be  simply  laid  on.  Any  attempt  to  draw 
the  bandage  taut  will  result  in  constriction  of  the  neck,  with 
great  discomfort  to  the  patient. 

Barton's  Bandage. — ^This  bandage  is  of  especial  use  in  frac- 
ture of  the  lower  jaw,  but  it  may  be  used  to  hold  a  dressing 
in  place  in  any  region  covered  by  it. 

A  two-inch  bandage  is  started  at  the  top  of  the  head  and 
carried  downward  behind  the  left  ear,  around  the  back  of 


106 


BANDAGING 


tlu>  neck  and  forward  alonj;-  the  ri<,dit  side  of  the  jaw  to  the 
chin.  Curvinf;-  in  front  of  the  chin  the  bancUige  runs  along 
the  left  side  of  the  jaw  below  the  left  ear,  to  the  back  of  the 
neck,  and  from  here  is  carried  upward  beliind  the  rijjht  ear 
to  the  startin.u--])oint.  From  tiiis  point  the  bandajfe  con- 
tinues in  tlie  same  direction  over  the  top  of  the  head  and 
downward  just  behind  the  left  eye  to  the  chin,  which  it  passes 
directly  under,  and  is  carried  upward  across  the  right  cheek, 
behind  the  right  e>e  to  the  starting-point.  This  completes 
the  bandage,  but  the  turns  may  be  repeated  several  times  for 
security. 


Fig.  64. — Barton's  bandage  f"i-  fracture  of  the  jaw.      (Wharton.) 


Bandage  of  the  Neck  and  Axilla. — A  dressing  of  the  axilla 
or  armpit  may  be  held  in  place  by  a  figure-of-eight  bandage 
of  the  neck  and  axilla.  The  bandage  is  fixed  by  two  circu- 
lar turns  around  the  upper  part  of  the  arm,  the  third  pass- 
ing upward  behind  the  shoulder  to  the  front  of  the  neck, 
around  the  neck,  in  front  of  the  shoulder,  under  the  arm- 
pit, behind  the  shoulder,  and  again  to  the  front  of  the  neck; 
thus  forming  a  figure-of-eight.  This  figure-of-eight  turn  may 
be  repeated,  and  if  desired,  circular  turns  about  the  neck  or 
arm  may  be  added. 

Bandage  of  the  Chest  and  Axilla. — This  bandage  is  adapted 
to  hold  a  dressing  in  one  axilla. 


THE   ROLLER  BANDAGE 


107 


The  bandage  starts  in  the  midhrie  and  is  carried  over  the 
shoulder  and  around  beneath  the  injured  armpit,  across  in 
front  of  the  chest,  under  the  armpit  of  the  opposite  side  and 
across  the  back  to  the  shoulder  of  the  injured  side.  From 
here  the  bandage  passes  downward  under  the  axilla,  across 
the  back  to  the  opposite  axilla  and  around  to  the  front  of 
the  chest  at  the  starting-point. 

Figure-of-eight  Bandage  of  the  Chest. — This  bandage  starts 
over  the  breast-bone  and  passes  to  the  right  shoulder,  curv- 
ing behind  it  to  the  axilla  and  forward  on  the  chest  to  the 
starting-point.  From  here  it  passes  obliquely  across  the 
chest  in  the  same  direction  to  the  left  shoulder,   around 


Fig.  65. — Antericir  figure 


(Wharton.) 


which  it  passes  to  the  left  axilla,  running  forward  and  across 
the  chest  to  the  starting-point.  This  completes  the  anterior 
iigure-of -eight  of  the  chest.  The  posterior  figure-of-eight 
of  the  chest  is  made  in  a  similar  manner,  starting  from  the 
midline  of  the  back. 

Breast  Bandage. — This  may  be  made  to  retain  dressings  or 
to  make  pressure  on  one  or  both  breasts.  To  bandage  the 
right  breast  the  roller  is  started  beneath  the  breast  and 
carried  horizontally  across  the  chest  from  right  to  left, 
entirely  around  the  chest  to  the  starting-point.  It  then 
passes  obliquely  upward  over  the  lower  margin  of  the  right 
breast  to  the  left  shoulder,  passing  over  it  and  then  down- 
ward across  the  back  and  around  the  chest  one  inch  above 


108 


BANDAGING 


tlu*  first  horizontal  turn.    When  tliis  is  completed  a  second 
oblique  turn  is  made  about  an  inch  above  the  first.    These 


Fig.  66. — Bandage  to  support  right  breast.     (Wharton.) 


Fig.  67. — Bandage  of  l)oth  breasts.     (Wharton.) 


THE  ROLLER  BANDAGE 


109 


turns  are  continued  alternately  until  the  breast  is  entirely 
covered. 

If  it  is  desirable  to  cover  both  breasts  the  first  two  turns 
are  made  as  above.  The  third  turn  passes  around  the  chest 
to  the  back,  from  whence  it  passes  upward  to  the  right 
shoulder  and  obliquely  downward  across  the  chest  below 
the  lower  margin  of  the  left  breast,  passing  around  to  the 
back  to  overlap  the  circular  turns. 


Fig.  68. — Velpeau  bandage.     (Wharton.) 


These  three  turns  are  alternated:  first  the  circular  turn, 
then  the  oblique  turn  to  the  right  breast,  passing  from  below 
upward,  followed  by  another  circular  turn,  and  finally  an 
oblique  turn  passing  from  above  downward,  supporting  the 
left  breast.  In  the  double  bandage  the  best  support  is  given 
to  the  breast  on  the  side  where  the  oblique  bandage  passes 
from  below  upward.  In  the  above  case  the  bandage  applied 
to  the  right  breast  gives  the  best  support.  If  the  left  breast 
requires  a  greater  support,  this  bandage  should  be  reversed. 

Circular  Bandage  of  the  Chest  and  Abdomen. — ^In  the  male 
the  breasts  may  be  bandaged  by  a  circular  spiral  running 
either  upward  or  downward.  The  abdomen  may  be  ban- 
daged in  the  same  manner. 


no  BANDAGING 

The  Velpeau  Bandage. — This  })anda<;'o  is  used  to  fix  the  arm 
and  i'urearin  ati;aiiist  the  ehest.  The  forearm  of  the  extrem- 
ity to  be  bandaged  is  placed  obliquely  across  the  chest  with 
the  fingers  near  the  opposite  collar-bone.  For  the  right  arm 
the  bandage  is  fixed  by  a  circular  turn  about  the  chest, 
passing  from  right  to  left.  It  is  then  carried  across  the  back 
to  the  injured  shoulder  and  downward,  over  the  point  of 
the  shoulder,  across  the  outer  side  of  the  upper  arm,  turning 
on  itself  to  be  carried  across  the  front  of  the  chest  just  above 
the  first  circular  tiu-n,  passing  entirely  around  the  chest. 
When  the  elbow  is  reached  this  turn  passes  in  front  of  the 
elbow,  holding  it  firmly  against  the  chest  and  passing  to  the 
left  side  of  the  chest;  from  this  point  the  bandage  passes 
obliquely  upward  across  the  back  to  the  left  shoulder  and  is 
continued  as  described  above,  each  turn  overlapping  the 
preceding  until  the  arm  is  covered.  This  bandi'ge  is  espe- 
cially applicable  to  fractures  of  the  collar-bone. 


CHAPTER   V. 
FRACTURES  AND  DISLOCATIONS. 

When  an  injui\y  results  in  a  wound  of  the  skin  it  is  usually 
fairly  easy  to  determiiue  the  nature  of  the  injury  from  inspec- 
tion of  the  injured  part.  But  when  the  body  is  injured  by  a 
blow  with  a  blunt  instrument,  or  by  a  fall,  it  is  much  more 
difficult  for  the  first-aid  worker  to  determine  the  extent  of 
the  injury  to  the  deeper  parts.  There  may  be  a  sprain  or 
dislocation,  a  bone  may  be  broken,  one  of  the  vital  organs 
may  be  torn  or  ruptured,  or  there  may  be  only  a  simple 
bruise  or  contusion  of  the  tissues. 

Some  idea  of  the  extent  of  the  injury  may  be  gained  from 
the  appearance  of  the  patient.  After  a  severe  injury  there 
is  usually  considerable  shock,  the  face  is  pale,  the  pulse  is 
weak,  and  there  is  evidence  of  great  pain.  The  converse  of 
this  is  not  always  true.  Very  rarely  we  see  patients  who  are 
suffering  from  fractures  or  other  severe  injuries,  who  have 
apparently  very  little  pain.  In  the  excitement  of  an  accident 
a  patient  with  a  severe  injury  may  temporarily  forget  his 
own  pain  and  be  of  aid  in  helping  others.  On  the  other  hand, 
some  persons  are  so  constituted  that  even  the  sight  of  blood 
causes  a  nervous  shock  which  makes  them  turn  pale  and  grow 
weak  and  faint.  As  a  result  they  may  appear  to  be  severely 
injured. 

In  practice  give  every  case  the  benefit  of  the  doubt  and 
treat  as  severely  injured  every  patient  who  shows  evidence 
of  shock  until  you  are  reasonably  certain  that  no  serious 
injury  is  present. 

FRACTURES. 

When  a  bone  is  broken  it  is  said  to  be  fractured  and  the 
break  is  called  a  fractiu*e.  It  is  commonly  believed  that  a 
fractured  bone  is  different  from  a  broken  bone.  This  is  an 
error;  they  are  one  and  the  same  thing. 


112  FRACTURES  AXD   DISLOCATIONS 

Bones  may  be  broken  just  as  a  stick  of  wood  is  broken, 
directly  across,  the  two  ends  beinj;  separated;  they  may  be 
spht  longitucHnally  or  obHqnely;  or  a  chip  or  hirfj;er  piece 
may  be  broken  horn  the  end  or  side  of  the  bone  without 
permanently  interferinji;  with  the  function  or  usefulness  of  the 
bone. 

In  young  bones  there  is  considerable  elasticity,  so  that 
they  bend  a  little  before  breaking;  but  in  the  aged  the  bones 
are  brittle,  breaking  ^•ery  easily.  1  have  seen  a  child  fall 
two  stories  without  receivng  a  fracture,  and  I  have  treated  a 
man  of  eighty  who  fractured  his  thigh-bone  by  stepping  down 
oil'  the  curb.  In  some  cases  the  force  of  the  blow  will  drive 
one  fractured  end  of  the  bone  directly  into  the  other  frag- 


Fiii.  69. — Compound  fnicturc  of  the  tirru.     Note  the  end  of  the  h)\ver 
fragment  protruding  from  the  wound.     (Ashhurst.) 

ment.  This  is  called  an  impacted  fracture,  which,  when 
the  impaction  is  firm,  may  allow  the  patient  a  reasonably 
satisfactory  use  of  the  injured  arm  or  leg. 

If  you  will  cut  a  branch  from  a  tree  and  bend  it  you  will 
notice  that  the  branch  will  l)end  a  long  way  and  finally 
break  on  one  side  without  separating  entirely.  A  similar 
fracture  of  the  bones  occurs  in  children  and  is  known  as 
"  green-stick"  fracture. 

In  general,  fractures  are  of  two  kinds,  .ninylc  and  rompoinul. 

If  the  bone  is  fractured  without  an  associated  woinid  of 
the  skin,  the  fracture  is  said  to  be  simple.  A  compound 
fracture  is  one  in  which  the  injury  is  complicated  by  a 
woimd  of  the  overlying  soft  parts, 


FRACTURES 


113 


It  is  very  important  to  understand  the  diflerence  })e- 
tween  these  two  classes  of  fractures.  Compound  fracture  is 
exposed  to  infection  through  the  wound, 
and  has,  therefore,  more  serious  and 
dangerous  consequences.  In  compound" 
fracture  the  wound  may  result  from  an 
external  force,  such  as  a  blow  or  a  bullet 
wound;  or  the  jagged  end  of  the  bone 
may  be  forced  through  the  skin  from 
within.  When  bacteria  causes  infection 
of  a  wound  connected  with  a  broken 
bone,  the  bone  itself  is  apt  to  become 
infected  and  the  result  is  much  more 
serious  than  that  following  infection  of 
an  ordinary  wound. 

In  gunshot  fractures  the  fractures  are 
always  compound.  In  some  cases  the 
bullet  causes  a  shattering  of  the  bone 
in  many  pieces  (Fig.  70) .  A  fracture  of 
this  type,  whether  the  result  of  a  bullet 
wound  or  other  injury,  is  termed  a  com- 
minuted fracture. 

Symptoms  of  Fracture. — The  examiner 
recognizes  the  presence  of  fracture  by 
symptoms  and  physical  signs.  They  are : 

1.  Pain  and  tenderness. 

2.  Disability. 

3.  Deformity. 

4.  False  point  of  motion. 

5.  Crepitus. 

6.  Special  surgical  signs. 
Pain  and  Tenderness. — These  are  the 

most  important  of  all  the  signs,  and 
are  sometimes  the  only  signs  present. 
When,  after  an  injury,  the  patient  suf- 
fers severe  pain,  especially  when  any  at- 
tempt is  made  to  move  him,  a  fracture 
should  always  be  suspected.  If  the  pain  is  excruciating  in 
character,  causing  the  patient  to  cry  out  on  any  attempt  at 
motion,  there  is  almost  certainly  a  fracture  present. 


Fig.  70.  —  Injury  to 
bone  inflicted  by  steel- 
mantled  ball  at  1300 
yards.     (Park.) 


114 


FRACTURES  AND  DISLOCATIONS 


Temlenioss,  or  pain  on  })ressnre,  is  a  constant  symptom. 
In  examining  for  a  fracture  it  is  customary  to  aj)ply  lirm 


Fig.  71. — Longitudinal  splitting  fracture  of  the  tibia,  and  oblique  fracture 
of  the  fibula.     This  fracture  would  be  very  difficult  to  diagnose.     (Ashhurst.) 


pressure  over  the  bone  to  determine  where  tenderness 
exists.  When  the  tender  spot  is  found  a  special  examin- 
ation is  made  at  this  point.    If  firm  pressure  does  not  ehcit 


FRACTURES  115 

tenderness  at  any  point  there  is,  almost  certainly,  no  fracture 
present. 

The  exception  to  the  above  is  seen  during  loss  of  con- 
sciousness, when  the  detection  of  fracture  rests  chiefly  on 
false  point  of  motion,  deformity,  and  crepitus. 

Disability. — Partial  disability  is  the  rule  in  fracture. 
Usually  the  disability  is  immediate  and  marked,  increas- 
ing during  the  first  twenty-four  hours. 

In  impacted  and  green-stick  fractures,  as  well  as  in  incom- 
plete and  chipping  fractures,  the  disability  may  be  very  slight. 
A  chauffeur  drove  his  car  for  several  days  while  suffering 
from  a  fractured  wrist,  and  a  child  was  recently  seen  who 
played  about  the  house  for  over  a  week  with  only  slight 
evidence  of  disability  from  green-stick  fractures  of  both  bones 
of  the  forearm.  In  a  recent  drama  the  plot  rested  upon  the 
fact  that  it  was  impossible  for  a  man  who  had  just  broken 
his  wrist  to  hand  a  card  to  another  man  with  the  injured 
hand.  To  the  surgeon  who  has  seen  many  fractures,  this 
statement  is  as  absurd  as  the  common  belief  that  because 
the  fingers  can  be  moved  there  cannot  possibly  be  a  fracture. 
Remember  that  the  disability  depends  largely  on  the  sever- 
ity of  the  fracture.  Severe  fractures  with  complete  separa- 
tion of  the  bones  cause  the  most  disability. 

I  believe  that  the  inability  to  walk  is  an  important  sign  in 
fracture  of  the  lower  extremity.  While  the  foot  and  leg  may 
sometimes  be  moved  freely  without  pain,  the  patient  is  rarely 
able  to  bear  his  weight  on  the  fractured  leg. 

Deformity. — The  shape  of  the  limb  is  altered,  partially 
due  to  the  swelling  and  partly  to  the  break  m  the  bone. 
When  the  bone  is  near  the  skin  the  broken  ends  may  be 
felt.  In  other  cases,  the  shortening  and  the  crooked  appear- 
ance of  the  limb  must  be  depended  upon  in  order  to  make 
a  diagnosis. 

False  Point  of  Motion. — This  is  an  important  sign  when 
present.  If  the  limb  moves  at  a  point  where  there  is  ordi- 
narily no  joint,  the  bone  must  be  broken.  There  is  no  other 
alternative. 

Crepi'us.—li  you  rub  the  two  ends  of  the  broken  bone 
together  there   results   a  dull  grating   sensation   which  is 


no  FRACTURES  AXD   DISLOCATIONS 

transniittod  to  tlio  cxiunlnin.u  hands  and  can  sonu'tinics  even 
be  lieard.  This  is  called  crepitus  and  is  an  almost  certain 
sign  of  fracture. 

It  is  not  wise  for  the  first-aid  worker  to  elicit  either  false 
point  of  motion  or  crepitus  as  he  may  therehy  increase  the 
disi)lacement  of  the  fractured  ends.  These  symi)toms  should, 
however,  be  borne  in  mind,  us  they  are  frequently  noted  in 


Fk;.  72. — E(cliyiiio.si.s  tweiUy-four  hours  after  fracture  of  the  upper  end  <;f 
of  the  liunicrus.    Note  that  there  is  almost  no  visible  deformity.     (Ashhurst.) 

the  routine  examination  of  those  severely  injured.  "^1  hey 
are  both  absent  in  imjjacted  fractures  and  are  seldom  obtained 
in  fractures  without  displacement. 

Ecchymosis,  or  hemorrhage  beneath  the  skin,  is  a  common 
symptom  of  fracture.  It  becomes  evident  after  a  day  or  two 
and  appears  externally  as  the  common  "Idack-and-blue"  spot. 
Because  it  appears  so  late  it  is  of  little  value  in  the  early  diag- 


FRACTURES  117 

nosis  of  fractures.     It  also  occurs  after  simple  bruises  of  the 
soft  tissues, 

Sjwcial  Surgical  Signs.— In  addition  to  the  above  signs 
the  surgeon  determines  the  variety  and  extent  of  the  fracture 


Fig.  73.  —  X-ray  showing  callus  several 
weeks  after  fracture  of  the  radius.  After  a 
few  months  the  lump  in  the  region  of  the 
fracture     will    have    entirely    disappeared. 

(Ashhurst.) 


Fig.  74. — Fracture  of  the 
femur  with  healing  in  a 
deformed  position.  Vicious 
union.     (Park.) 


by  other  methods,  chiefly  the  measurement  of  the  affected 
parts  and  the  use  of  the  rr-rays.    The  latter  method  is  not 


US  FRACTURES  AXD  DISLOCATIONS 

available  for  emergency  work  but,  because  it.  o-ives  us  a  pic- 
ture of  the  fractured  bone,  it  will  be  used  in  the  discussion 
of  certain  fractures. 

Union  of  Fractures. — Healing  takes  place  by  the  growth, 
about  the  thickened  ends  of  the  bone,  of  a  tough,  fibrous 
material  called  callus.  This  begins  within  a  few  days,  and 
at  the  end  of  a  week  or  ten  days  results  in  a  fairly  firm  imion. 
It  gradually  changes  to  true  bone,  so  that  after  two  or  three 
months  the  bone  is  as  firm  at  the  point  of  the  fracture  as 
elsewhere.  An  .r-ray  taken  several  months  after  a  fractiu-e 
may  show  absolutely  no  evidences  of  the  injury. 

Treatment  of  Fracture. — When  the  broken  ends  are  dis- 
placed the  process  of  putting  them  together  is  called  reduc- 
tion. Splints  are  used  to  hold  the  fractured  ends  in  place 
(fixation).  The  special  forms  of  treatment  will  ])e  indicated 
imder  the  different  forms  of  fracture. 

First  Examine  the  Patient. — To  determine  if  a  fracture  is 
present  let  the  patient  lie  do^Mi  in  as  comfortable  a  position 
as  possible  and  examine  the  limb  through  the  clothing  for 
pain  or  deformity.  If  a  fracture  is  suspected,  remove  enough 
clothing  by  cutting  or  ripping  to  examine  the  injured  part. 
j\Iove  the  limb  as  little  as  possible,  thus  avoiding  pain  and 
the  danger  of  mcreasing  the  extent  of  the  injury.  When 
the  limb  is  exposed  examine  it  slowly  and  carefully  in  order 
to  determine  the  extent  of  the  fracture.  There  is  no  necessity 
for  hurry  in  such  a  case.  If  the  limb  shows  only  slight 
deformity  it  should  be  supported  on  a  soft  cushion  and  pro- 
tected until  the  arrival  of  the  physician.  Cold  compresses, 
that  is,  cloths  wet  in  cold  water  and  a]:)plied  to  the  injured 
part — will  relieve  the  pain.  If  there  is  a  marked  deformity 
the  attempt  may  be  made  to  correct  it  by  grasping  the  limb 
below  the  fracture  and  pulling  it  in  a  straight  line.  If  a  mod- 
erately strong  pull  does  not  reduce  the  deformity  the  attempt 
should  be  abandoned. 

^Yhile  it  is  desirable  to  secure  the  aid  of  a  physician  to 
reduce  the  fracture,  there  is  not  the  same  urgency  as  in  the 
case  of  wounds.  The  fracture  may  be  "set,"  or  reduced, 
even  after  several  days  have  elapsed.  There  is  no  harm  in 
allowing  the  patient  to  wait  several  hours,  or  longer,  if  the 


FRACTURES 


119 


fractured  bone  can  be  kept  at  rest.  For  those  cases  which 
must  be  moved  before  seeing  a  physician,  a  splint  of  scjme 
sort  must  be  apphed. 

SpHnts  are  made  of  thin  strips  of  wood  or  card-board  which 
may  be  bandaged  to  the  limb  so  as  to  prevent  the  separa- 
tion of  the  fractured  bones.  The  sphnt  shoukl  be  cut  long 
enough  to  include  the  joint  above  and  below  the  fracture, 
and  should  be  a  little  wider  than  the  thickness  of  the  limb. 
In  emergencies  any  form  of  a  straight  stick,  such  as  a  cane, 
an  umbrella,  or  a  branch  cut  from  a  tree,  will  serve  as  a 
temporary  splint.  Paste-board,  folded  newspapers,  sole 
leather,  and  strips  of  tin  have  been  successfully  used.    Ordi- 


FiG.  75. — Improvised  pillow  splint  for  fracture  of  the  leg.      (Brewer.) 

narily  a  most  satisfactory  splint  may  be  cut  from  the  thin 
wood  used  in  making  egg  cases,  or  other  similar  boxes  used 
in  the  grocery  trade. 

Every  splint  must  be  padded.  This  serves  two  purposes: 
It  makes  the  splint  fit  the  irregularities  of  the  limb,  conse- 
quently making  it  more  comfortable  for  the  patient,  and  the 
padding  allows  for  the  swelling  almost  certain  to  follow, 
which,  if  prevented  by  tight  bandages,  might  cause  added 
injury  to  the  limb.  Cotton  is  the  best  material  to  use  for 
padding,  but  if  this  is  not  available,  other  material  may  be 
used,  such  as  a  folded  blanket,  strips  of  cloth,  grass,  hay,  or 
any  other  elastic  material. 


120 


FRACTURES  AND  DISLOCATIOKS 


In  order  to  apply  the  splints  the  limb  is  held  by  an  assis- 
tant and  the  si)lints  ])la(cd  one  on  each  side  of  the  injured 
limb,  each  s])lint  well  ])n)lected  by  ])addiu<j  on  its  hmer  side. 
The  splint  is  fixed  in  place  either  with  a  bandaf;e,  with  strips 
of  cloth,  or  with  adhesive  plaster.  They  should  be  applied 
firmly  enough  to  hold  the  bone  in  position,  but  the  bandajiies 
should  never  be  tight  enough  to  cause  constriction.  If  the 
splints  are  a  little  wider  than  the  thickness  of  the  limb  the 
danger  of  constriction  is  minimized. 

A  bandage  should  never  be  applied  before  the  splint  is  in 
i:)lace.  The  reason  for  this  is  that  when  swelling  occurs  the 
bandage  will  be  much  too  tight. 


Fig.  76. — Side  splints  for  fracture  of  the  leg.     (Brewer.) 

In  some  cases,  such  as  fracture  of  the  skull  and  fractured 
ribs,  it  is  impossible  to  apply  a  splint;  and  in  others,  such  as 
fractiu'e  of  the  arm  near  the  shoulder,  it  is  simpler  to  bandage 
the  arm  firmly  against  the  side  of  the  body  than  to  use  a 
splint. 

After  the  splint  is  applied  the  patient  should  wait  for  the 
surgeon  with  the  limb  held  in  the  most  comfortable  position, 
or  he  may  be  taken  to  a  nearby  hospital  or  physician's  office. 
If  a  long  trip  must  be  taken  before  reaching  professional 
aid,  it  is  better  to  allow  the  patient  to  recover  from  the 
shock  of  the  injury  before  the  trip  is  made.  A  few  hours, 
or  even  a  day's  delay  is  not  of  serious  consequence. 

The  patient  should  be  moved  in  the  position  of  greatest 


FRACTURES 


121 


comfort.  If  the  wrist  is  fractured  and  the  distance  short 
the  patient  may  be  allowed  to  walk  with  the  wrist  supported 
by  the  other  hand  or  in  a  sling.  If  the  ankle  or  foot  is  frac- 
tured the  patient  may  ride  in  a  sitting  position  with  the 
foot  resting  on  a  cushion.  When  the  thigh  is  fractured  the 
recumbent  position  is  the  most  comfortable. 

Special  Fractures. — Fracture  of  the  Skull. — 1  his  may  be 
caused  by  a  blow  or  fall.  Any  portion  of  the  skull  may  be 
fractured.  It  may  be  associated  with  symptoms  of  concus- 
sion or  compression.^  Bleeding  from  the  mouth,  nose  or 
ears  is  seen  in  fracture  of  the  base  of  the  skull.  Pain  is 
sometimes  the  only  symptom. 


Fig.  77. — Showing  circumscribed  depressed  fracture  of  the  skull. 
(Stimson.) 

The  patient  should  be  put  to  bed  if  a  fractured  skull  is 
suspected,  even  if  he  feels  perfectly  well.  The  head  should 
be  slightly  elevated  and  an  ice-cap  or  cold  compress  applied. 
When  a  wound  is  present  it  should  be  dressed  and  a  bandage 
applied.  Because  of  the  danger  of  injury  to  the  brain,  a 
physician  should  be  summoned  at  once  in  all  suspected 
fractures  of  the  skull. 

Fracture  of  the  Spine. — This  is  a  very  serious  fracture.  It 
may  be  suspected  when,  after  an  injury  to  the  back  or  neck, 
the  patient  cannot  move  the  legs.    There  are  usually  severe 


1  Concussion  and  compression  are  fully  desci'ibed  under  Regional  Injuries. 


122 


FRACTURES  AND  DISLOCATIONS 


shock,  associated  witli  sliootint:;  i)aiiis  on  any  attempt  at 
movement. 

Movement  may  increase  the  deformity  and  cause  irrepa- 
rable damage  to  the  dehcate  spinal  cord,  so  that  it  is  better  to 
allow  the  patient  to  lie  quietly  until  the  surgeon  arrives. 
iNIeantime  a  blanket  may  be  secured  and  mild  stimulation 
may  be  given,  such  as  hot  cofi'ee,  or  a  few  drops  of  aromatic 
spirits  of  ammonia. 


Fig.  78. — Reeonstructod  skull  showing  the  many  frafturcs  resulting 
from  a  gunshot  wound.     (Park.) 


If  it  is  absolutely  necessary  to  remove  the  patient,  it  should 
be  done  as  carefully  as  possible.  A  stretcher  should  be 
secured  and  the  patient  placed  on  it,  great  care  being  taken 
not  to  bend  the  spine,  the  patient  being  kept  flat  on  a 
stretcher  or  cot  and  not  allowed  to  attempt  to  sit  up  while 
being  moved. 


FRACTURES 


123 


Fracture  of  the  spine,  if  it  injures  the  spinal  cord,  usually 
causes  paralysis  of  the  lower  limbs,  which  may  never  disap- 
pear.   Sudden  death  may  occur  during  transportation. 

Fracture  of  the  Nose. — As  a  result  of  the  injury  the  bridge 
of  the  nose  is  apt  to  be  pushed  to  one  side.  As  a  rule, 
nothing  is  done  until  the  surgeon  arrives.  Cold  compresses 
may  be  applied  and  measures  taken  to  stop  the  bleeding  from 
the  nose  if  it  is  profuse.  If  it  is  not  possible  to  secure  profes- 
sional aid  for  several  days,  firm  pressure  may  be  made  in  the 


1.  xWf^ 


Fig.  79. — Fracture  of  the  nose,  eighteen  hours  after  injury.     (Ashhurst.) 


direction  opposite  to  the  deformity,  slightly  overcorrecting 
it.  Unless  there  is  a  wound  a  dressing  is  not  required.  The 
treatment  for  bleeding  from  the  nose  will  be  discussed  else- 
where. 

Fracture  of  the  Jaw. — Usually  the  result  of  blows  or  falls. 
Movement  of  the  jaw  is  very  painful  and,  on  examination 
of  the  mouth,  inequality  of  the  teeth  may  be  noted  at  the 
point  of  fracture.  False  point  of  motion  and  crepitus  may 
be  made  out  when  the  jaw  is  moved.  The  treatment  con- 
sists in  a  temporary  bandage  to  hold  the  teeth  of  the  upper 


124  FRACTURES  AND  DISLOCATIONS 

jaw  and  tlie  lower  jaw  firmly  together,  the  upper  jaw  thus 
acting  as  a  splint.  The  Barton  bandage  and  the  four-tailed 
bandage,  both  of  which  are  suitable,  have  already  been 
described.  If  considerable  time  must  elapse  before  a  physi- 
cian is  seen,  an  antiseptic  mouth  wash  such  as  peroxide  of 
hydrogen  or  weak  solution  of  carbolic  (1  per  cent.)  should 
be  used  to  ])revent  infection.  Any  of  tlie  commercial  mouth 
washes  may  be  used  for  the  same  ])urpose.  Hemorrhage  is 
rarely  troublesome.  If  persistent  the  patient  shoidd  be  given 
small  pieces  of  ice  to  suck. 


Fig.  80. — Applioation  of  the  four-tailed  bandage  as  a  temporary  dressing  for 
fracture  of  the  jaw.     (Stimson.) 

The  diet  should  consist  entirely  of  milk  and  otlier  fluid 
nutrients,  taken  through  a  tube  without  removing  the 
bandage. 

Fracture  of  the  Dental  Margin  of  the  Jaw. — Often  a  blow  in 
the  mouth  results  in  the  loss  of  one  or  more  teeth,  with  or 
without  breaking  ofl'  the  adjoining  portion  of  the  jaw.  When 
first  seen  the  teeth  are  often  directed  inward,  attached  only 
by  a  small  strip  of  mucous  membrane.  In  such  cases  the 
teeth  and  detached  bone  should  be  forced  back  into  place 
at  once  and  the  patient  taken  to  a  surgeon  or  dentist.    The 


FRACTURES 


125 


jaw  is  bandaged  and  a  nioutli   wash  j)rcs('ril)e(l  exactly  as 
described  above  for  coni])lete  fracture  of  the  jaw. 

Fracture  of  the  Collar-bone. — If  the  collar-bone  is  broken 
the  irregularity  of  the  bone  at  the  point  of  fracture  can  be 
easily  felt.  The  patient  should  be  placed  flat  on  his  back 
on  the  bed  or  floor  and  allowed  to  remain  in  this  position 
until  the  surgeon  arrives.  If  he  must  be  moved,  the  uppre 
arm  should  be  bandaged  to  the  side  with  a  circular  bandage 
including  the  arm  and  the  chest,  and  the  hand  carried  in  a 
sling.    The  Velpeau  bandage  is  well  adapted  to  this  injury. 


Fig.  81. 


-Modified  Velpeau  bandage  applied  for  fracture  of  the  clavicle 
(Ashhurst.) 


Fracture  of  the  Ribs. — Usually  the  result  of  falls,  but  may 
follow  severe  coughing  spells.  The  chief  symptoms  are 
pain,  made  worse  by  moving  or  deep  breathing,  and  a  short, 
dry  cough.  Tenderness  at  the  point  of  pressure  and  pain 
referred  to  the  region  of  the  fracture  when  firm  pressure  is 
made  on  the  front  of  the  chest  are  common  sjinptoms. 
The  treatment  consists  in  rest  in  bed  together  with  the 
application  of  a  firm  circular  bandage  about  the  chest  or  a 
broad  band  of  adhesive  plaster  may  be  applied  a  little  more 
than  half-way  around  the  chest.    The  pain  may  be  relieved 


126 


FRACTURES  AM)  DISLOCATIONS 


by  the  use  of  an  icc-t-ap  or  hot-water  bag  over  tlie  painful 
area. 

Fracture  of  the  Arm. — ^l^he  arm  hanj;s  helpless  at  the  side; 
the  patient  involuntarily  supports  the  forearm  on  the  injured 
side  with  the  other  hand.  \Vhen  the  arm  is  examined 
there  is  a  local  point  of  tenderness,  and,  usually,  a  false  point 
of  motion  at  the  location  of  the  fracture. 


Fig.  62.  —  Adhesive  plaster 
strapping  for  fracture  of  the 
ribs.     (Ashhurst.) 


Fiu.  S3. — Fracture  of  the  upper 
end  of  the  left  humerus.  The  arm 
is  swollen  and  there  is  a  small  area 
of  ecchymosis  in  front  of  the  shoul- 
der. Note  that  there  is  only  slight 
deformity.     (Stimson.) 


Treatment. — In  some  cases  it  may  be  sufficient  to  place  a 
pad  of  cotton  or  other  suitable  material  between  the  arm 
and  the  chest  and  to  bandage  the  arm  against  the  chest. 
In  other  cases,  where  the  fracture  is  associated  A\'ith  consid- 


FRACTURES 


127 


erable  deformity  it  is  better  to  apply  a  pad  between  the  arm 
and  the  chest,  and  a  padded  spHnt  reaching  from  the  shoulder 
to  the  elbow  on  the  outer  side  of  the  arm.  In  both  cases  the 
arm  is  held  against  the  chest  by  a  circular  bandage,  the 


Fig.  84. — X-ray  showing  fracture  of  the  humerus.     (Ashhurst.) 


elbow  being  bent  at  a  right  angle  and  the  forearm  supported 
by  a  sling. 

Fracture  of  the  Elbow. — ^The  forearm  should  be  placed  in 
the  most  comfortable  position  and  left  in  this  position  until 
the  surgeon  arrives.     Cold  compresses  relieve  the  pain.     If 


128  FRAcrrRFs  Axn  dislocations 

the  i)ati(."iit  must  \)v  iiiovod  it  is  best  to  allow  the  arm  to 
remain  on  tho  pillow  which  is  supported  by  the  other  hand. 
In  some  cases  it  is  suHicieiit  to  support  the  elbow  and  fore- 
arm hi  a  wide  slin<r. 


Fig.  So. — Method  of  applj-ing  splints  for  fracture  of  the  lower  part  of 
the  humerus.  The  bandage  includes  the  forearm  and  hand  in  order  to  give 
additional  support.     The  elbow  is  bent  at  a  right  angle.     (Ashhurst.) 


Fig.  86. — Fracture  of  both  bones  of  the  forearm,  somewhat  resembling 
CoUes's  fracture.     (Park.) 

Fracture  of  the  Forearm. — In  severe  injuries  both  bones  are 
fractured.    The  elbow  is  bent  to  a  right  angle  and  a  padded 


FRACTURES 


129 


splint  placed  along  the  back  of  the  forearm  extending  horn 
the  elbow  to  the  tips  of  the  fingers.  A  similar  splint  is  i)laced 
on  the  opposite  side  of  the  hand  and  a  bandage  applied. 
Care  must  be  taken  in  the  a])plication  of  the  bandage  not 
to  bind  too  tightly.  Even  a  bandage  which  is  loose 
enough  at  first  may  become  too  tight  when  the  arm  begins 


Fig.  87. — X-ray  showing  fracture  of  both  bones  of  the  forearm.      (Park.) 


to  swell.  A  tight  bandage  is  recognized  by  pain  and  numb- 
ness of  the  fingers,  which  feel  cold  to  the  examining  hand. 
The  tips  of  the  fingers  should  always  be  left  exposed  so  that 
they  may  be  easily  examined.  When  it  is  believed  that  the 
bandage  is  too  tight  it  should  be  loosened  at  once.  A  bandage 
applied  too  tightly  is  worse  than  none, 


130 


FRACTURES  AND  DISLOCATIONS 


Fracture  about  the  Wrist.-  Traiis\crse  fracture  of  the  radius 
about  one  inch  above  the  wrist-joint  is  the  fracture  most 
frequently  seen  in  surj^ieal  practice.  It  is  called  "Colles's 
fracture,"  and  results  from  a  fall  on  the  })alm  of  the  hand 


Fig. 


SS. — Fracture  of  the  wrist  sliowinj^  the  t.N'pieal  sih'er-fork  defi)rniity. 
(Ashhiir.st.) 


with  the  hand  extended.  The  deformity  is  typical,  and  is 
called  "siher-fork  deformity,"  from  its  resemblance  to  an 
ordinary  table  fork,  the  fingers  represent inti;  the  tines  of  the 
fork. 


Fig.  89.- 


-Posterior  splint  for  fracture  of  the  wrist.     Padding  omitted  for 
photograph.     (Ashhurst.) 


The  emergency  treatment  is  the  same  as  for  fracture  of 
the  forearm.  In  some  cases  a  single  splint  (Fig,  89)  is 
sufficient. 

Fracture  of  the  Hand. — This  is  usually  a  fracture  of  one  of 
the  metacarpal  bones.     The  hand  is  swollen  and  there  is 


FRACTURES 


131 


severe  pain  on  pressure  over  the  fracture.  Because  the 
adjoining  bones  give  support  to  the  injured  bone  there  is 
often  very  little  disability.  A  i)added  splint  should  be 
placed  along  the  back  of  the  hand  from  about  two  inches 
above  the  wrist  nearly  to  the  tips  of  the  fingers.  The  hand 
is  bandaged  to  this  suj^port  and  carried  in  a  sling. 

Fracture  of  a  Finger. — The  finger  may  be  supported  by 
bandaging  it  to  the  adjacent  finger,  or  a  narrow  splint  may 
be  applied.  In  the  case  of  the  thumb  a  splint  should  extend 
from  the  wrist  along  the  back  of  the  thumb  nearly  to  the  tip. 
In  many  cases  no  dressing  is  required,  it  being  sufficient  to 
protect  the  fingers  from  injury  by  carrying  the  hand  in  a 
sling. 


Fig.  90. — Fracture  of  the  right  femur.    The  patient  Ues  helpless  with  the  toes 
of  the  injured  foot  directed  away  from  the  other  foot.     (Stimson.) 


Fracture  of  the  Thigh. — If  the  patient  is  resting  comfort- 
ably in  bed  no  splint  is  required,  but,  if  it  is  necessary  to 
move  him  before  the  surgeon  arrives,  a  long  splint  reaching 
from  the  armpit  to  the  foot  and  about  four  inches  in  width 
should  be  bandaged  to  the  body  and  to  the  injured  leg. 
When  the  patient  is  transported  he  should  be  moved  on  a 
stretcher  or  cot.  If  wheel  transportation  is  required  a  cot 
placed  in  a  delivery  wagon  serves  admirably. 

Fracture  of  the  Knee-cap. — The  patient  is  unable  to  stand 
and  the  knee-cap  is  extremely  tender.  The  knee-joint  is 
swollen  because  the  blood  escapes  directly  into  the  joint. 
A  long,  padded  splint  should  be  applied  along  the  back  of 


132 


FRACTURES  AND   DISLOCATIONS 


the  leg,  exttMidint;-  from  the  l)iitt()cks  to  the  heel.     The  i)atient 
may  be  alloweil  to  sit  up,  proxided  the  knee  is  not  bent. 


Fk;.  91. — Fractuio  of  the  kncc-ctiii.      (Park.) 

Fracture  of  the  Leg. — Two  lateral  i)ad(le(l  splints  should  be 
applied,  each  about  three  inches  in  width  and  extending 
from  above  the  knee  to  the  ankle.     The  same  precautions 


Fig.  92. — Fracture  of  the  leg  about  two  inches  alxne  the  ankle.    There  is 
marked  angular  deformity.     (Stimson.) 

that  have  been  outlined  in  the  treatment  of  fracture  of  the 
forearm,  are  necessary  here  to  prevent  constriction  of  the 


FRACTURES 


133 


leg.  A  pillow  folded  about  the  leg,  or  a  blanket  made  into 
a  double  roll  and  bandaged  about  the  leg,  may  be  used  in 
emergency  treatment  of  this  fracture.  (See  Figs.  75  and  7(5.) 
Fracture  of  the  Ankle. — A  fracture  of  the  lower  end  of  the 
fibula  with  turning  outward  of  the  foot  is  called  "Pott's 


Fig.  93. — Showing  the  lines  of  frac- 
ture in  Pott's  fracture.     (Park.) 


Fig.  94. — Exaggerated  deform- 
ity in  Pott's  fracture.     (Park.) 


fracture."    Like  a  Colles's  fracture  of  the  wrist,  this  injury 
is  of  frequent  occurrence. 

If  there  is  deformity,  it  is  most  marked  externally,  the  foot 
being  bent  outward.  In  applying  splints  the  deformity 
should  first  be  overcorrected,  the  ankle  being  bent  slightly 


134, 


FRACTURES  AND   DISLOCATIONS 


inward.     The  foot  should  not  be  allowed  to  drop  downward 
but  should  be  fixed  in  position  at  a  ri,ij;ht  angle  to  the  lej?. 


Fig.  95. — Pott's  fracture  of  ankle  showing  marked  swelling  hut  only 
slight  deformity.     (Stimson.) 

A  single  lateral  splint,  or  double  lateral  splints,  should  be 
applied  similar  to  those  described  above  in  fracture  of  the  leg. 


Fig.  9G. — Spliiit  applied  for  Pott's  fracture.     This  not  only  holds  the 
bone  in  place  but  tends  to  correct  the  deformity.     (Stimson.) 


except  that  the}'  shf)uld  begin  below  the  knee  and  extend  a 
short  distance  beyond  the  foot.     The  single  splint,  with  pad- 


DISLOCATIONS  .  135 

ding  along  the  inner  side  of  the  leg  above  the  ankle  (Fig.  96), 
is  easy  to  apply  and  is  followed  by  most  satisfactory  results. 
It  is  always  placed  along  the  inner  side  of  the  leg. 

Fracture  of  the  Foot  and  Toes. — A  bandage  applied  over  a 
thick  layer  of  cotton  is  usually  all  that  is  required  for  frac- 
ture of  the  foot,  care  being  taken  to  leave  the  tips  of  the  toes 
exposed.  If  the  toes  become  numb  and  cold  the  bandage  is 
too  tight.  If  fracture  of  the  foot  is  suspected  the  patient 
should  not  be  allowed  to  walk  on  the  injured  foot,  even  though 
he  is  able  to  walk  with  only  slight  pain. 

When  a  toe  is  broken  it  is  usually  sufficient  to  support  it 
by  bandaging  it  to  the  adjacent  toe. 

Compound  Fractures.  —  As  has  already  been  noted,  a 
compound  fracture  is  a  fracture  associated  with  a  wound. 
This  must  be  treated  very  carefully,  because  infection  is 
very  apt  to  occur.  It  is  better  to  leave  the  wound  untouched 
until  sterilized  material  can  be  obtained  than  to  apply  an 
infected  dressing. 

When  all  material  is  at  hand  the  best  treatment  is  as 
follows : 

1.  Wash  the  hands  well  with  soap  and  water,  followed  by 
an  antiseptic  such  as  alcohol.  Do  not  dry  the  hands  unless 
you  use  a  sterile  towel. 

2.  Swab  the  wound  out  well  with  tincture  of  iodin  (one- 
half  strength),  being  careful  to  reach  all  the  crevices  of  the 
wound. 

3.  Then  paint  the  skin  with  tincture  of  iodin  for  several 
inches  from  the  edge  of  the  wound. 

4.  Apply  a  sterile  dressing. 

5.  Bandage  loosely,  bearing  in  mind  the  dangers  of  con- 
striction due  to  subsequent  swelling. 

6.  Apply  splints  in  the  usual  manner. 

DISLOCATIONS. 

A  dislocation  is  the  separation  of  two  bones  normally 
joined  together  to  form  a  joint.  It  may  occur  as  simple 
dislocation,  one  bone  being  merely  displaced  from  its  normal 
position,  or  as  fracture  dislocation,  in  which  case  there  is  a 


130  FRACTURES  AND  DISLOCATIONS 

chipping  away  of  one  margin  of  the  joint  cavity  which  allows 
the  articulating'  bone  to  slip  out  of  the  cavity  or  as  a  com- 
1)()UU(1  dislocation,  in  which  case  there  is  an  associated 
wound. 

Every  joint  is  surrounded  by  a  tough  fibrous  membrane,  the 
capsule,  which  forms  a  cuff  extending  from  one  bone  to  the 
other  across  the  joint.  At  certain  points  the  capsule  is  thicker 
and  stronger,  forming  ligaments.  When  a  bone  is  dislocated, 
the  capsule  and  ligaments  are  torn,  the  dislocated  bone 
usually  slipping  through  this  opening  in  the  capsule. 

Symptoms. — The  s^^Bptoms  are  pain,  deformity,  disabil- 
ity, and  limitation  of  motion  of  the  affected  joint. 

Treatment. — The  treatment  of  dislocation  consists  of  the 
reduction  or  "setting"  of  the  dislocation,  and  measures  to 
relieve  the  pain  and  to  permit  healing.  Reduction  consists 
of  making  the  dislocated  head  of  the  bone  retrace  the  steps 
it  took  in  the  process  of  dislocation;  to  pass  backward 
through  the  same  opening  in  the  capsule  and  to  enter  the 
"socket"  of  the  joint.  The  pain  may  be  relieved  by  rest 
and  the  application  of  cold  compresses. 

When  the  bone  is  in  j  lace  and  the  part  kept  at  rest  the 
torn  capsule  and  ligaments  heal  by  scar  tissue.  This  is 
fairly  firm  in  ten  days  or  two  weeks,  but  is  not  as  firm  as 
normal  until  five  or  six  weeks  have  elapsed. 

Habitual  Dislocation. — Habitual  dislocation  is  the  name 
given  to  those  cases  where  the  same  joint  is  easily  and 
frequently  dislocated.  If  the  limb  is  not  kept  at  rest  the 
dislocation  is  apt  to  recur  before  the  torn  ligaments  are 
firmly  healed,  and  if  this  is  frequently  repeated  a  permanent 
opening  is  left  in  the  capsule  through  which  the  head  of  the 
bone  easily  slips.  Patients  who  are  subject  to  recurrent 
dislocations  sometimes  can  reduce  the  dislocation  Avithout 
aid.  If  the  joint  is  kept  at  re^t  for  ten  days  or  two  weeks 
after  a  dislocation  and  excessive  motion  prevented  for  several 
weeks  longer  the  condition  is  not  apt  to  recur. 

Persistent  Dislocation,- — Persistent  dislocation  is  a  dislo- 
cation which  luis  not  been  reduced.     If  reduction  is  not 

1  Forming  a  joint.  Two  bones  forming  a  joint  are  said  to  articulate  and 
the  joint  itself  is  called  an  articulation. 


DISLOCATIONS  137 

accomplished  during  the  first  week  it  is  apt  to  be  very  diffi- 
cult or  even  impossible  to  effect  it.  The  best  time  to  reduce 
a  dislocation  is  within  a  few  hours  after  the  injury,  before 
the  swelling  has  become  pronounced.  A  delay  of  a  day  or 
two,  however,  is  rarely  serious. 


Fig.  97. — Diagram  showing  forward  dislocation  of  the  shoulder.     Note  that 
the  head  of  the  bone  has  slipped  out  of  the  socket.     (Speed.) 

Patients  with  an  unreduced  dislocation  finally  recover 
some  use  of  the  limb,  the  head  of  the  bone  forming  an  imper- 
fect joint  in  its  new  location;  but  the  degree  of  motion  is 
limited,  and,  at  the  best,  only  a  fraction  of  the  normal 
movement  of  the  joint. 

Special  Dislocations. — Dislocation  of  the  Spine.^ — Disloca- 
tion of  one  vertebra  upon  the  other  may  occur.  It  is  usually 
associated  with  injury  to  the  bones  and  spinal  cord,  and  the 


13S 


FRACTURES  AND  DISLOCATIONS 


symptoms  and  treatment  are  essentially  the  same  as  for 
fracture  of  the  spine. 

Dislocation  of  the  Clavicle. — The  joint  at  either  end  of  the 
clavicle  may  be  dislocated.  It  may  be  possible  to  slip  the 
dislocated  end  in  place  by  drawinji;  the  shoulders  directly 
back\\'anl,    at   the   same   time   pressin<2;   directly   ui)on   the 


Fig.  98. — Anterior  dislocation  of  the  upper  end  of  the  left  humerus. 
(Stimson.) 


projecting  end  of  the  bone.  A  VeliJean  bandage  or  other 
similar  bandage  may  be  applied  with  a  pad  over  the  dislo- 
cated end  of  the  bone. 

Dislocation  of  the  Shoulder. — This  is  a  common  form  of 
dislocation.  The  head  of  the  bone  usually  lies  in  front  of 
the  joint  beneath  the  clavicle.    The  motion  of  the  shoulder 


DISLOCATIONS  139 

is  limited  and  the  patient  is  unable  to  place  the  hand  on  the 
opposite  shoulder. 

To  reduce  the  dislocation  the  patient  is  placed  on  his  back 
on  a  cot  or  table,  and  an  assistant  standing  on  the  opposite 
side  holds  the  patient  about  the  chest  close  to  the  armpit. 
The  operator  now  grasps  the  injured  wrist  and  pulls  firmly 
and  steadily  at  right  angles  to  the  body.  After  pulling  for 
a  few  minutes,  in  order  to  tire  the  muscles,  the  arm  is  slowly 
brought  down  to  the  side,  the  steady  pull  being  kept  up  in 
the  long  axis  of  the  arm.  A  second  assistant  may  make 
pressure  on  the  head  of  the  bone. 


Fig.  99. — Unreduced  fracture  dislocation  of  the  elbow.     Side  view. 
(Ashhurst.) 

In  muscular  individuals  it  is  often  impossible  to  reduce 
the  defoi*mity  without  an  anesthetic.  In  such  cases  a  tem- 
porary dressing  is  applied  by  placing  a  large  pad  of  cotton 
under  the  arm  and  bandaging  the  arm  to  the  chest.  The 
elbow  is  bent  and  the  wrist  supported  in  a  sling  until  the 
services  of  a  surgeon  can  be  secured. 

If  reduction  has  been  successful  the  above  dressing  is 
applied  to  prevent  recurrence.    Too  much  force  should  not 


140 


FRACTURE,^  AXD   DISmCAriONS 


be  resorted  to  in  attempts  at  reduction,  because  there  is 
danger  of  fracturing  the  bone  itseU'  antl  thus  acUUng  a  serious 
eompHcation  to  the  original  injury. 

Dislocation  of  the  Elbow. — ^This  is  usually  a  fracture- 
dislocation.  It  is  best  treated  as  a  fracture  until  ])rofessi()nal 
assistance  can  be  secured.    Cold  compresses  relieve  the  pain. 

In  rare  cases,  where  a  phy- 
sician cannot  be  secured  for 
several  days,  an  attempt  may 
be  made  to  reduce  it  as  fol- 
lows: The  elbow  is  bent  at  a 
right  angle  and  the  arm  allowed 
to  hang  by  the  side,  the  pa- 
tient being  in  a  sitting  position. 
The  wrist  is  grasped  by  one 
hand  and  held  firmly  while  the 
operator  makes  pressure  dowTi- 
ward  with  the  other  hand  at 
a  point  on  the  forearm  adja- 
cent to  the  crease  at  the  elbow. 
When  the  muscles  are  relaxed, 
an  assistant  grasps  the  arm 
just  above  the  elbow  and  draws 
it  in  a  direction  away>|^from 
the  hand.  If  this  is  successful 
the  bones  will  come  together 
with  a  click.  In  order  to  prevent 
recurrence  the  arm  is  bound  to 
the  chest  with  the  elbow  bent 
to  a  little  less  than  a  right 
angle.  After  the  third  or  fourth 
day  the  arm  may  be  removed 
daily  from  the  bandage  and 
the  joint  moved  a  little,  but, 
except  for  this,  it  should  be  firmly  bandaged  to  the  chest 
for  at  least  two  weeks.  It  should  be  carried  in  a  sling  for 
two  or  three  weeks  longer. 

Dislocation  of  the  Wrist. — This  is  an  extremely  rare  dislo- 
cation.    Most  cases  which  appear  to  be  dislocations  are 


Fig.  100. — Di.sloration  of  the 
elhow  backward.  Outline  draw- 
ing of  bones.      (Speed.) 


DISLOCA  TfONS 


141 


fractures  of  the  lower  end  f)f  tlie  radius.     (See  Colles's  frac- 
ture.)   The  treatment  is  the  same  as  for  fracture. 

Dislocation  of  the  Fingers. — The  finger  should  be  pulled  in 
the  long  direction  of  the  fingers  until  the  hone  slips  into 


Fig.  101. — Diagrammatic  sketch  showing  dislocation  of  the  thumb. 
This  can  usually  be  reduced  by  pulling  the  thumb  toward  the  ends  of  the 
fingers.     (Park.) 

place.  Pressure  may  be  made  on  the  projecting  end  of  the 
bone.  A  cold  compress  held  in  place  by  a  bandage  relieves 
the  pain  and  gives  all  the  support  required. 

Dislocation  of  the  Jaw. — This  is  a  not  uncommon  disloca- 
tion, and  usually  occurs  when  yawning  or  laughing.    The  jaw 


Fig.  102. — Method  of  reducing  dislocation  of  the  lower  jaw,     (Park.) 

is  held  wide  open  and  cannot  be  closed.  To  reduce  the 
dislocation  the  patient  is  placed  upright  in  a  chair,  and  the 
operator,  standing  in  front  of  him,  places  the  thumbs  on 
either  side  upon  the  lower  back  teeth  and  presses  do-un- 


142 


FRACTURES  AND  DISLOCATIONS 


ward  aiul  thou  a  little  backward.  The  jaw  will  siiaj)  into 
place.  Ill  ortler  to  protect  the  thumbs,  they  should  be  well 
^^Tapped  with  a  strip  of  gauze  or  a  handkerchief,  otherwise 
they  may  be  injured  when  the  jaws  snap  together. 


Fig.  10.3. — Deformity  due  to  dislocation  of  the  upper  end  of  the  femur 
backward.     This  is  a  common  form  of  hip  dislocation.     (Stimson.) 


D/SLOdA  TIONH  143 

Dislocation  of  the  Hip. — The  patient  lies  helpless  and  is 
unable  to  move  the  injured  thigh.  This  is  a  very  difficult 
dislocation  to  reduce.  The  attempt  may  be  made  as  follows: 
With  the  patient  lying  on  his  back  and  held  })y  an  assistant, 
the  leg  is  steadily  and  firmly  pulled  directly  downward.  It 
is  then  slowly  moved  outward  until  it  forms  an  angle  of  about 
60  degrees  with  the  other  leg.  At  this  point  it  is  slowly 
rotated,  until  the  toes  on  the  injured  side  are  directed  a  little 
outward  and  finally,  the  pull  being  constantly  kept  up,  the  leg 
is  brought  back  to  the  midline  again.  If  this  is  not  successful 
it  is  better  to  wait-for  the  arrival  of  the  surgeon.  If  the  patient 
must  be  transported  he  should  be  carried  on  a  cot  or  stretcher. 
A  splint  is  not  required. 

Dislocation  of  the  Patella. — This  is  a  rare  form  of  disloca- 
tion. The  patella  is  usuall}"^  dislocated  outward  or  simply 
turned  on  edge.  Direct  pressure  will  often  cause  it  to  snap 
back  into  place.  The  knee  should  be  kept  stiff  with  a 
posterior  splint  for  several  weeks. 

Dislocation  of  the  Knee. — Almost  always  a  fracture  dislo- 
cation.    Should  be  treated  as  a  fracture. 

Dislocated  Meniscus. — In  the  knee  there  is  a  small  piece  of 
cartilage,  triangular  in  shape,  called  the  meniscus.  This 
may  be  caught  between  the  two  bones,  causing  the  knee  to 
"lock."  The  patient  has  a  sharp  pain  and  falls  to  the  ground 
and  is  unable  to  bend  the  knee. 

If  the  patient  is  placed  upon  his  back  so  that  the  muscles 
are  relaxed  and  attempts  made  to  move  the  knee  the  carti- 
lage will  usually  slip  out  from  between  the  bones.  Follow- 
ing this  the  patient  is  able  to  walk  with  only  slight  pain  but 
in  a  few  hours  the  knee  begins  to  swell  and  is  very  painful. 
For  this  reason  the  patient  should  be  put  to  bed  at  once  and 
cold  compresses  applied  to  the  knee. 

As  this  condition  is  apt  to  recur,  patients  soon  learn  to 
unlock  the  joint  without  aid. 

Dislocation  of  the  Ankle  and  Foot. — Any  dislocation  in  this 
region  is  apt  to  be  associated  with  fracture,  and  should  be 
treated  as  such. 

Dislocation  of  the  Toes. — Dislocation  of  the  toes  is  treated 
in  the  same  manner  as  dislocation  of  the  fingers. 


144  FRACTURES  AXD   DISLOCATIONS 

SPRAINS. 

When  a  joint  is  subjected  to  sufficient  strain  to  tear  the 
H.uanicnts  a  sprain  results.  In  dislocation  the  liijjaments  tear 
and  the  bone  slips  out  of  the  socket,  but  in  s])rain  the  injury 
stops  Avhen  the  lipuneuts  are  torn,  so  that  a  sprain  may  be 
considered  as  a  beginning  dislocation. 

Among  first-aid  workers  a  common  error  is  to  mistake  a 
fracture  for  a  sprain.  More  than  half  of  the  "sprains" 
which  come  to  the  surgeon  for  treatment  prove  to  be  frac- 
tures. Always  hesitate  to  diagnose  a  case  as  sprain  unless 
there  is  very  slight  disability.  For  example,  if  a  patient 
can  walk  without  difficulty,  but  has  a  painful  and  swollen 
ankle,  the  case  is  probably  a  sprain.  If  the  injury  is  severe 
enough  to  prevent  walking  it  is  almost  certainly  a  fracture. 

There  is  an  old  saying  that  "a  bad  sprain  is  worse  than  a 
break."  This  is  an  error  which  arose  because  many  injuries 
were  diagnosed  as  sprains  and  treated  as  sprains  when  they 
really  were  fractures.  As  a  consequence  the  constant  irri- 
tation of  the  fractured  bone  which  was  not  put  in  a  splint 
caused  more  pain  and  disability  than  a  fracture  which  was 
recognized  and  treated  as  such.  Until  you  have  considerable 
experience  suspect  a  fracture  in  every  case  of  "sprain"  of 
even  moderate  severity. 

Treatment. — In  general,  sprains  may  be  treated  by  one  of 
two  methods. 

The  first  method  consists  of  rest  combined  with  the  appli- 
cation of  cold  for  one  or  two  days  followed  by  firm  ban- 
dages and  massage  with  gradually  increasing  use  of  the 
joint. 

The  second  method  consists  of  massage  and  a  firm  bandage 
from  the  first,  allowing  the  patient  moderate  use  of  the 
injured  limb  from  the  time  of  the  injury.  The  bandage 
must  be  applied  very  firmly  and  removed  daily  for  massage 
which  must  always  be  in  the  direction  of  the  flow  of  venous 
blood,  that  is,  toward  the  heart.  Care  must  be  taken  in  this 
method  not  to  cause  constriction  of  the  limb  by  the  use  of 
a  bandage  which  is  too  tight.  Adhesi^'e  straps  serve  admir- 
ably as  a  support.    They  should  be  applied  so  as  to  nearly 


HPIiAINH 


145 


surround  the  liml),  a  narrow  space  \)ii\n\i,  left  to  allow  for 
swelling. 

The  method  chosen  depends  somewhat  upon  the  severity 
of  the  injury.  The  first  method  should  be  chosen  if  there  is 
the  slightest  possibility  of  fracture. 

In  any  case  where  pain  and  disability  persist  for  more  than 
a  few  days  a  physician  should  be  consulted.  As  most  sprains 
must  be  treated  on  general  principles^  only  a  few  will  be  given 
in  detail. 


Fig.  104. — Sprained  riffht  ankle.     Note  the  swelling  especially  on  the 
outer  side.     (Ashhurst.) 


Sprained  Ankle. — This  is  the  most  common  and  typical 
sprain  and  will  consequenth'  be  discussed  first.  Usually  the 
ligaments  on  the  outer  side  of  the  ankle  are  torn  and  the 
ankle  is  especially  tender  at  this  point.  The  usual  history 
of  a  sprained  ankle  is  that  the  patient  "turns"  the  ankle. 
After  a  moment  of  severe  pain  he  is  able  to  walk  with  very 
little  pain.  Several  hours  later  when  the  swelling  becomes 
more  extensive  the  pain  grows  very  severe  again.  In  fracture 
of  the  ankle  this  period  of  comparative  comfort  is  usually 
absent. 
10 


146  FRACTURES  AND  DISLOCATIONS 

Either  luclliDcl  uf  treatiucut  may  hv  used.  If  the  sprahi 
is  not  too  severe  the  ankle  may  be  strapped  or  l)aiidaf!;ed 
firmly  and  the  patient  allowed  to  walk  from  the  first  day. 
The  bandage  should  be  worn  for  about  three  weeks.  To 
prexent  recm'rence  laced  shoes  should  be  worn  for  sex'eral 
months. 

Sprained  Wrist. — Tliis  is  rart-ly  se\ere.  A  tij;ht  bandage 
or  a  leather  wrist  sui)])ort  keeps  tlie  w  rist  sufliciently  at  rest 
until  healing  can  take  place. 

Sprained  Fingers. — The  fingers  and  thumb  are  frecjuently 
sprained.  Usually  a  bandage  for  a  few  days  is  all  that  is 
required.  If  the  pain  persists,  adhesive  straps  may  be  used 
for  support. 

Sprained  Knee. — Sprained  knee  is  usually  caused  by  a 
twisting  injury.  The  joint  may  become  greatly  swollen, 
owing  to  exudation  of  serum  into  the  knee-joint  (water  on 
the  knee).  In  such  cases  the  patient  should  be  i)ut  to  bed 
with  an  ice-cap  a])])lied  to  the  afl'ected  knee.  After  three 
days,  when  the  swelling  and  pain  have  decreased,  the  knee 
should  be  well  wrapped  in  cotton,  a  firm  bandage  applied 
and  the  patient  allowed  to  \\alk  about.  During  the  subsid- 
ing stage  massage  and  hot  application  Mill  serve  to  aid 
recovery. 

Sprained  Back. — The  term  "s})rained  back"  usually 
includes  several  different  conditions.  True  sprain  consists 
of  injuries  to  the  ligaments  between  the  pehis  and  the  spine 
or  between  the  various  \'ertebnc,  caused  by  sudden  twist- 
ing or  bending  of  the  back.  The  same  injury  may  cause  a 
tearing  or  rujiture  of  the  thick  muscles  of  the  back,  this  latter 
condition  being  termed  a  strain  in  contradistinction  to  the 
tearing  of  the  ligaments,  which  is  a  sprain. 

A  closely  allied  condition  known  as  luml)ago  may  follow 
exposure  to  cold,  especially  when  combined  with  unusual 
muscular  exertion.  Clinically,  these  three  conditions  are 
hard  to  differentiate  and  they  are  consequently  all  treated 
in  the  same  manner. 

Treaiment. — In  severe  cases  the  patient  is  confined  to  bed 
but  ordinarily  he  merely  avoids  active  muscular  exercise. 
A  combination  of  three  forms  of  treatment  is  advised: 
Massage,  support  and  the  application  of  heat. 


WOUNDS  OF  BON  EH  AND  JOINTS  147 

Massage  tends  to  increase  the  })1()()(]  supi)ly  and  to  carry 
off  the  extravasated  blood  which  is  always  present  in  the 
tissues  after  a  sprain  or  strain. 

Support  may  be  secured  by  a  heavy  bandage  applied  around 
the  back  and  abdomen,  or  by  a  wide  canvas  belt.  Overlap- 
ping strips  of  adhesive  plaster,  extending  across  the  back  and 
well  onto  the  abdomen,  is  one  of  the  most  satisfactory  forms 
of  support.  For  the  chronic  cases  canvas  elastic  belts  and 
other  mechanical  supports  have  been  devised. 

The  application  of  heat  may  be  made  with  the  ordinary 
hot-water  bottle  or  bag,  or  with  hot  cloths  or  sand-bags. 
Usually  dry  heat  acts  best. 

A  satisfactory  form  of  treatment,  combining  heat  and 
massage,  consists  in  placing  the  patient  face  downward  in 
bed,  covering  the  back  with  a  piece  of  flannel  and  ironing 
the  back  with  a  hot  iron.  The  movement  of  the  iron  up  and 
down  the  back  serves  as  massage. 

WOUNDS    OF   BONES    AND   JOINTS. 

Closely  allied  to  fractures  and  dislocations  are  wounds  of 
bones  and  joints.  When  bones  are  wounded  the  injury  is 
practically  a  compound  fracture  even  if  only  a  small  cut 
has  been  made  in  the  bone.  The  treatment  is  the  same  as 
for  compound  fracture. 

In  wounds  of  the  joints  there  are  the  same  dangers  of 
infection  and  blood-poisoning  as  in  the  case  of  compound 
fracture.  The  preliminary  treatment  of  the  wound  is  the 
same  and  the  necessity  of  adequate  professional  care  is  even 
more  urgent  than  it  is  in  compound  fractures. 

Bullet  Wounds  of  the  Bones  and  Joints. — The  introduction 
of  a  bullet  or  other  foreign  body  into  a  bone  or  joint  increases 
the  probability  of  infection.  While  the  bullet  itself  is  apt 
to  be  sterile  it  carries  into  the  wound  pieces  of  clothing  and 
dirt  from  the  surface  of  the  body  so  that  the  wound  is 
almost  certainly  infected.  The  first-aid  treatment  consists 
in  the  application  of  tincture  of  iodin  to  the  wound  and 
surrounding  skin  together  with  the  transportation  of  the 
patient  to  a  hospital  or  other  point  where  skilled  sm'gical 


14S 


FUAcrrUKS    AM)    DISLOCATIOXS 


attention  may  ])v  secuird.  Do  not,  on  any  account,  probe 
the  wound  or  attenii)t  to  remove  the  bullet.  Such  attempts 
onh'  succeed  in  introduciui;-  more  infection  into  the  woimd. 


Fius.  10.",  :iiHl  nil,. — Expciiniciital  Kuii.shot  fractures  with  .oO  and  .38  calibre 
IjuUela  at  high  velocity.      (U.  S.  Army  Med.  Museum.) 

During  transportation  the  part  should  be  kept  at  rest  by 
the  use  of  an  appropriate  splint. 


CHAPTER   VI. 
MISCELLANEOUS  INJURIES. 

BURNS. 

Burns  may  be  caused  by  contact  with  fire  or  hot  sub- 
stances or  by  contact  with  certain  chemicals.  All  burns  are 
the  result  of  destruction  of  tissue  either  by  the  action  of 
heat  or  chemicals. 

For  convenience  of  description  burns  are  divided  into  three 
classes  or  degrees. 

A  first-degree  burn  is  one  in  which  there  is  simple  red- 
dening of  the  skin,  such  as  is  seen  as  a  result  of  sunburn. 
In  this  only  the  most  superficial  layer  of  the  skin  is  injured 
and  there  is  no  blister  formation.  Healing  is  not  accom- 
panied by  scar  formation. 


Fig.  107. — Scald  of  back  of  hand  twenty-four  hours  after  injury,  showing 
blister  formation.     (Ashhurst.) 

A  second-degree  burn  is  the  most  common  type,  the 
destruction  of  tissue  extending  deeper,  with  the  formation 
of  blebs  or  blisters.  In  cases  which  do  not  become  infected 
scar  formation  is  comparatively  slight. 

Third-degree  burns  are  associated  with  destruction  of  the 
entire  thickness  of  the  skin,  occasionally  with  charring  of 
the  tissues.    Extensive  scar  formation  follows  healinsf. 


150 


^[ISCELL^xEO^s  ix.r fries 


As  the  ^e^^•e  supply  of  the  skin  is  very  abundant,  burns 
are  extremely  painful  and  are  apt  to  be  accompanied  by 
considerable  shock. 

The  sex'erity  of  a  burn  depends  upon  two  factors:  the 
degree  anil  the  extent  of  the  burn.  First-degree  burns,  if 
extensive,  are  apt  to  be  followed  by  serious  results.  An 
extensive  burn  caused  by  steam  or  hot  water,  although 
entirely  of  first  or  second  degree  may  result  in  death. 

Symptoms. — The  symptoms  var>'  with  the  extent  of  the 
buiMi.  In  small  superficial  burns  i)ain  and  redness  of  the 
skin  are  tb.e  only  symptoms.    In  deeper  burns  blister  forma- 


Fio.  108. — Scald  of  l)ack  of  hand,  showing  blister  formation.     (Brewer.) 


tion  occurs  shortly  after  the  injury.  In  extensive  ])urns 
and  in  those  of  the  third  degree  there  is  a  ]ieriod  of  shock 
with  weak  pulse  action  and  subnormal  temperature.  This 
lasts  from  a  few  minutes  to  several  hours  and  is  then  fol- 
lowed by  a  period  of  reaction  with  fever.  This  fever  may 
subside  or  it  may  be  continued  because  of  aljsorption  from 
the  })urned  area  or  from  infection  of  the  denuded  surfaces. 

]3urns  in  children  are  apt  to  be  more  severe  and  are  more 
often  fatal  than  in  adults. 

First  Pvt  Ovt  the  Fire. — If  the  clothes  are  burning,  wrap 
the  patient  in  a  rug,  blanket,  or  other  woolen  wraj).  If 
nothing  of  the  sort  is  at  hand,  make  the  patient  lie  down  and 


BURNS  151 

roll  over  on  the  ground  and  beat  the  fire  with  your  coat 
or  other  similar  object.  If  water  is  available  it  should  be 
thrown  on  the  burin'ng  clothing,  but  it  is  not  advisable  to 
leave  the  patient  in  order  to  secure  water.  On  no  account 
should  the  patient  be  allowed  to  walk  or  run  in  search  of 
help. 

Treatment. — For  first-degree  burns,  such  as  sunburn  or 
superficial  burns  with  hot  steam,  an  application  of  bland 
oil,  such  as  vaselin  or  cold  cream,  will  relieve  the  pain,  and 
is  usually  all  that  is  required. 

For  small  second-degree  burns,  such  as  frequently  occur 
and  are  commonly  treated  at  home,  the  application  of 
a  bland  oil,  such  as  vaselin  or  olive  oil,  covered  with  a 
dressing  of  absorbent  cotton,  will  relieve  the  pain  and  aid 
healing.  In  order  to  prevent  subsequent  infection,  an  oint- 
ment composed  of  10  per  cent,  boric  acid  in  vaselin  is  pref- 
erable to  a  non-antiseptic  dressing.  If  the  facilities  are 
available  the  skin  should  be  well  cleansed  with  soap  and 
water  before  applying  the  ointment.  In  the  care  of  these 
small  burns  it  is  usually  unnecessary  to  consult  a  phy- 
sician. 

The  burn  is  dressed  daily,  the  blebs  not  being  punctured 
unless  they  are  large  and  troublesome,  in  which  case  they 
may  be  nicked  on  one  side  with  a  pair  of  sharp  scissors, 
previously  sterilized.  If  infection  becomes  evident  (increased 
pain  and  redness  with  the  presence  of  pus)  a  physician  should 
be  consulted.  A  moderately  severe  local  burn  should  be 
entirely  well  at  the  end  of  the  second  week. 

Carron  oil^  was  previously  widely  used  in  the  treatment  of 
burns.  During  recent  years  boric  acid  ointment  has  been 
given  the  preference  because  of  its  antiseptic  qualities,  but 
in  very  painful  burns  carron  oil  may  be  preferred  because 
of  its  cool,  soothing  character.  Other  substances  which  may 
be  used  in  an  emergency  are  olive  oil,  fresh  lard,  cotton- 
seed oil,  or  any  other  bland  oil.  Butter  is  not  suitable  because 
its  high  percentage  of  salt  increases  the  pain.     Wet  dress- 

1  Carron  oil  is  a  mixture  of  equal  parts  of  linseed  oil  and  lime-water,  well 
shaken  to  form  an  emulsion.  It  is  freely  applied  to  the  injured  surfaces 
and  covered  with  cotton  or  gauze. 


152 


M  ISC  ELL  A  XEO  US  J  A  ./ 1 '  R/LS 


ings  of  l)it'arb()nate  of  so'la  (ordiuan'  Uakinu'  soda)  in  1  or  2 
l)or  cent,  solutions'  may  l)e  used. 

In  small  burns  which  become  infected,  the  contents  of  the 
blister  taking  on  the  characteristics  of  pus  (becoming  thick 
and  turbid),  it  is  best  to  cut  the  bleb  entirely  away  and  to 
a])])ly  a  w(>t  dressing  of  2  per  cent,  boric  acid  solution. 

Severe  Bums. — These  cases  recjuire  the  ser\ices  of  a 
physician  as  soon  as  possible.  The  patient  should  be  put 
to  bed  at  once  and  treatment  started  for  the  accomjianying 
shock.  Uemember  that  in  severely  burned  patients  the 
temi)erature  is  apt  to  be  subnormal  and  that  the  body  heat 
should  !)(>  ])reserved. 


Fig.  109. — Showing  mcthij(t  nl  ticatiiiK  a  severe  bui'ii  by  the  use  of  skin 

grafts.      (Ashhurst.) 

Treatment. — The  clothing  should  })e  carefully  cut  away 
and  renio\'ed  except  such  portions  as  may  be  stuck  to  the 
skin,  which  should  not  be  disturbed.  One  of  the  oils  men- 
tioned above  should  be  thickly  applied  and  covered  with 
gauze  or  cotton  held  in  place  by  a  loose  bandage. 

For  the  ])ain,  some  form  of  anodyne  must  be  gi\-en,  pref- 
erably under  the  instructions  of  a  physician;  but  if  medical 
care  is  not  available,  morphin,  |  grain  repeated  after  half 
an  hour  if  necessary,  should  be  given  at  once.  Opium,  | 
grain,  or  paregoric,  1  teaspoonful,  may  be  given  in  the  same 
manner.  While  the  use  of  medications  of  this  sort  is  very 
dangerous  in  unskilled  hands  it  is  preeminently  proper  in 


'  A  rounded  teaspoonful  of  hicurhouatc  of  soda  or  boric  acid  to  a  pint 
of  water  makes  approximately  a  1  per  cent,  solution. 


BURNS  153 

such  a  case  to  give  some  sort  of  aiuxlyiie  to  deaden  tlie  i);iin 
when  medical  advice  is  unobtainable. 

If  the  pulse  is  ra])id  and  weak  and  the  patient  is  evidently 
in  collapse,  stimulation  should  be  given  as  outlined  under 
the  treatment  of  shock.  The  careful  cleansing  of  the  burned 
area  should  be  omitted  until  the  patient  has  recovered  from 
the  primary  shock. 

Afterward  the  burns  can  be  exposed,  cleansed  and  care- 
fully dressed.  There  is  always  absorption  from  the  burned 
areas  causing  fever  for  several  days  or  longer.  During  this 
period  (which  may  last  for  weeks)  the  patient  should  be 
kept  in  bed  on  a  full,  nourishing  diet,  careful  attention  being 
given  to  general  nutrition,  digestion,  bowels,  skin,  etc. 
Burns  which  become  infected  should  be  dressed  with  gauze 
kept  wet  with  2  per  cent,  boric  acid  solution. 

The  healing  of  extensive  burns  is  apt  to  be  very  long 
drawn  out,  lasting  for  weeks  or  months. 

Chemical  Burns. — Burns  may  be  caused  by  strong  acids, 
such  as  sulphuric  or  nitric  acids;  by  strong  alkalies,  such  as 
caustic  soda,  potash  and  quicklime;  or  by  chemical  irritants, 
such  as  iodin,  capsicum,  mustard,  etc. 

The  injury  caused  by  a  strong  acid  or  a  strong  alkali  is 
different  from  the  ordinary  burn.  The  lesion  is  destructive 
from  the  beginning,  there  being  no  blister  formation.  On 
the  other  hand,  the  chemical  irritants  cause  marked  blister 
formation  with  little  or  no  tissue  destruction. 

Treatment. — The  first  step  consists  in  the  removal  of  the 
excess  of  the  chemical  present,  either  by  wiping  it  away  or 
by  washing  it  oft'  with  water.  Wipe  the  excess  off  with  a 
handkerchief  or  whatever  else  you  have  at  hand  and  then 
look  for  water. 

Certain  substances  may  be  used  to  neutralize  the  caustic. 
Acids  should  be  neutralized  with  weak  alkalies.  Bicarbonate 
of  soda  is  usually  available  in  an  emergency,  but  any  other 
weak  alkali,  such  as  milk  of  magnesia  or  lime-water,  may  be 
used.  x\lkalies  should  be  neutralized  b}^  weak  acid  solutions, 
such  as  vinegar  or  lemon  juice.^ 

1  Vinegar  is  a  dilute  solution  of  acetic  acid;  lemon  juice  contains  citric 
acid. 


154  ^fISCELLANEOUS  INJURIES 

Carbolic  acid  is  unlike  other  acids  in  that  it  is  not  neu- 
tralized by  alkalies.  Carbolic  acid  burns  should  be  immedi- 
ately washed  with  alcohol  or  solutions  containiui;-  alcohol, 
such  as  whisky  or  brandy. 

In  burns  due  to  irritants  the  excess  of  irritant  should  be 
removed.  Runnin<2;  water  will  remove  a  certain  percentage  of 
most  irritants,  but  in  some  cases  the  substance  is  more 
easily  and  quickly  removed  by  other  solutions.  INIustard 
can  be  removed  by  the  use  of  oil  or  soap  and  water;  alcohol 
will  remove  capsicum  or  iodin.  After  the  chemical  has  been 
removed  as  completely  as  possible  a  bland  ointment  is  ai>])lied 
and  the  l)iu-n  dressed  daily  in  the  same  manner  as  a  burn 
caused  by  heat. 

INJURIES  CAUSED  BY  COLD. 

Cold  may  cause  local  injury  or  a  general  chilling  of  the 
entire  body. 

Exposure  to  Cold. — In  healthy  persons  exposed  to  extremely 
low  temperatures  for  long  periods,  and  in  others  (especially 
when  weakened  by  cNbaustion  or  starvation)  exposed  to  tem- 
peratiu-es  comi)aratively  considerably  higher,  the  entire  body 
may  be  chilled,  the  result  being  depression  of  the  vital  jn-o- 
cesses  which,  if  continued,  may  finally  lead  to  insensibility  and 
death. 

In  soldiers  weakened  by  exhaustion,  sickness,  and  insuffi- 
cient food  the  bad  effects  of  exposure  to  cold  are  freciucntly 
seen. 

The  patient  is  weak,  depressed,  and  hardly  able  to  move 
about,  complaining  of  a  sensation  of  numbness  and  fatigue. 
The  pulse  is  wt>ak  and  the  temperature  is  subnormal.  The 
skin  of  the  hands  and  feet  is  bluish  or  i)urplish  in  color. 

Treatment. — If  the  condition  is  not  marked  it  is  sufficient 
to  get  the  patient  to  a  warm  place  and  give  hot  drinks,  such 
as  hot  coffee,  broth  or  hot  water.  If  unable  to  reach  shelter 
at  once  a  fire  should  be  built  and  hot  drinks  pre])ared. 

Alcoholic  drinks  may  be  given  in  small  doses  when  the 
patient  is  in  warm  quarters.  Never  give  alcohol  to  such  a 
patient  until  thv  jicriod  of  exposure  is  over.    The  action  of 


INJURIES  CAUSED  BY  COLD  155 

alcohol  is  simply  to  dilate  the  surface  bloodvessels,  giving 
ail  artificial  sense  of  warmth,  while  at  the  same  time  allowing 
a  further  dissipation  of  body  heat  if  the  surrounding  air  is 
much  below  body  temperature. 

In  severe  cases  the  patient  is  put  to  bed  between  warm 
blankets,  the  body  is  rubbed  with  the  hands  or  warm  rough 
towels,  and  hot  drinks  given  as  directed  above. 

If  the  patient  is  unconscious,  an  enema  of  eight  ounces  of 
coffee  solution  is  injected  into  the  rectum  and,  if  necessary, 
artificial  respiration  is  begun. 


\  ^1 

Wa 

^^/k              ^      \    •  ,98 

W  .        .IHjH 

■jjjj^^^l^H^Ml       V      \.  'm-Tl 

ul                                    ^^^^^^1 

U      J                       ^^^^^1 

^^^^^^^^^L  #31 

r  f             fl^^H 

i^^mH 

1/  /  ^^j^^^^H 

Fig.  110. — Frost-bite  of  hands  four  days  after  injury.     Notice  resemblance 
to  burns  with  blister  formation.     (Ashhurst.) 

Frost-bite. — With  or  without  the  general  eflfects  of  cold, 
the  fingers,  toes,  ears,  or  even  an  arm  or  leg  may  be  frozen, 
resulting  in  what  is  known  as  frost-bite.  The  part  first 
becomes  numb  and  blue  and  later,  white  and  stiff. 

In  the  mildest  degree  of  frost-bite  the  hands  and  feet, 
after  exposure  to  cold,  become  red  and  swollen  (chilblains), 
and  there  is  a  sensation  of  burning  and  itching.  In  more 
severe  cases,  as  the  circulation  returns,  there  is  an  exuda- 
tion of  serum  beneath  the  outer  layer  of  the  skin  and  blisters 
result.  In  still  more  severe  cases  the  circulation  does  not 
return  to  the  fingers  and  toes  affected,  and  the  part  remains 


156 


Ml^CELLAXEO US  IXJ URIES 


pale  and  bloodless.  Later  gangrene  results  and  tlie^gan- 
grenous  area  tiu-ns  blaek. 

Treatment. — For  chilblains  the  feet  should  be  bathed  dail\- 
\vith  applications  of  alternating  hot  and  cold  water.  \Mien 
exjjosetl  to  cold,  warm  stockings,  which  are  removed  when 
indoors,  should  be  worn.  Stimulation  of  the  skin  with  alcohol 
or  si)iritsof  cami)h()r  tends  to  relieve  the  i)ain  and  to  i)rcvent 
recurrence. 

When  actual  frost-bite  has  occurred,  the  fingers,  hands, 
or  other  ])arts  affected,  should  be  rubl)e(l  with  water  which 
is  gradualh-  warmed.    The  old  belief  that  a  frost-bite  should 


m 

Jg^M 

1 

1^  *■"  •';>«,  jj 

^^^^ 

HI 

Fig.  111. — Result  of  frost-bite  after  two  days  and  nights  of  exposure. 

(Park.) 


be  rubbed  with  snow  or  ice-water  has  been  proved  an  error. 
However,  it  is  not  desirable  to  secure  too  rapid  a  reaction, 
so  that  it  is  better  to  start  with  water  about  room  tempera- 
ture. x\fter  the  circulation  returns  the  parts  are  loosely 
wrapped  in  cotton  and  a  bandage  ai)plied.  If  blisters  or 
gangrene  occurs  the  lesion  should  be  treated  in  exactly  the 
same  manner  as  a  burn. 

A  special  form  of  frost-bite  is  caused  by  applying  an  ice- 
cap directly  to  the  skin.  A  superficial  ulceration  results 
Avhich  is  called  an  "ice-cap  burn."  If  care  is  taken  never  to 
apply  an  ice-cap  without  a  towel  or  piece  of  gauze  between 
the  bag  and  the  skin,  this  injury  will  not  occur. 


INJURIES  CAUSED   HY  Kl.liCTKK'ITY 


\:n 


INJURIES    CAUSED   BY   ELECTRICITY. 

Electricity  causes  injury  tiu-ou^h  its  local  action,  rcsultinji; 
in  a  burn;  or  through  its  general  action,  resulting  in  i)rostra- 
tion  and  unconsciousness,  a  condition  analagous  to  that  of 
surgical  shock. ^ 


Fig.   112. — Electric  burns  of  right  forearm  and  neck  due  to  current  from 
"live  wire"  carrying  1200  volts.     (Park.) 


It  is  most  important  that  the  person  be  removed  at  once 
from  the  influence  of  the  current.  A  dry  stick  of  wood  or 
piece  of  rope  may  be  used  to  break  the  contact,  or  the 
patient  may  be  dragged  away  from  the  contact  by  catching 

'  The  tsrm  shock,  used  surgically,  has  not  the  same  meaning  as  when  used 
in  reference  to  electricity.  However,  severe  electric  shocks  may  cause 
surgical  shock  in  the  same  manner  as  any  other  injury. 


158 


MISCELLANEOUS  INJURIES 


hold  of  a  portion  of  his  clothing.    Do  not  hesitate  because 
'the  i^atient  is  apparentlN'  lifeless.     UecoNcries  have  occurred 
after  many  minutes  of  apparent  death. 


Fig.  113. — X-ray  Ijiirii,  the  result  of  too  long  exposure  to  the  .r-rays.     (Park.) 


After  the  electrical  contact  has  been  broken  the  patient 
should  be  examined  immediately  to  determine  the  extent  of 
the  injury.  If  he  has  stopped  breathing,  artificial  respira- 
tion should  be  begun  at  once.  In  this  case  every  instant  is 
of  \alue,  consecpiently  the  patient  should  not  be  moved  from 
the  immediate  vicinity  of  the  accident.     Continue  artificial 


BITE    WOUNDS  159 

respiration  until  the  patient  breathes  normally  or  until  a 
physieian  arrives.  If  no  physician  can  be  (jbtained  artificial 
respiration  should  be  kept  up  for  at  least  an  hour. 

When  the  breathing  is  normal  the  patient  should  be  put 
to  bed  and  the  general  treatment  for  surgical  shock  insti- 
tuted. The  local  burns  caused  by  the  action  of  electricity 
should  be  treated  in  the  same  manner  as  any  other  burn. 

X-ray  burns  are  a  particular  kind  of  electric  burns.  They 
result  from  exposure  to  the  direct  rays,  and  may  follow 
exposure  for  only  a  few  minutes.  The  burn  does  not  make 
its  appearance  for  several  days  after  the  exposure.  Great 
care  should  be  exercised  by  those  who  work  about  .r-ray 
machines  not  to  expose  themselves  to  the  direct  rays  from 
the  light. 

BITE   WOUNDS. 

Dog  Bite.— The  wound  caused  by  the  bite  of  a  dog,  cat 
or  other  animal  is  usually  a  lacerated  one,  and,  to  a  large 
extent,  the  treatment  is  the  same  as  for  any  other  wound. 
But  bites  have  certain  general  and  special  characteristics 
which  differentiate  them  from  other  wounds. 

In  the  first  place  they  are  very  apt  to  be  infected  with 
the  ordinary  pus  organisms.  If  you  stop  to  consider  the 
dirt  and  filth  that  is  eaten  by  animals  with  their  food,  it 
is  easy  to  understand  that  their  mouths  must  contain  large 
numbers  of  bacteria.  In  addition,  hydrophobia  is  spread  by 
the  bite  of  the  "mad  dog,"  so  that  this  disease  must  always 
be  considered.  While  most  cases  of  hydrophobia  are  caused 
by  dog  bites,  the  disease  may  be  transmitted  by  any  animal. 
Wounds  m^ade  through  the  clothing  are  less  dangerous  than 
wounds  of  the  hands  and  face,  because  the  virus  is  wiped 
from  the  animal's  teeth  as  they  pass  through  the  clothes. 

Treatment. — Because  any  animal  may  be  suffering  from 
hydrophobia,  and  because  of  the  possibility  of  infection  with 
ordinary  pus  germs  from  any  bite,  every  bite  wound  should 
be  cauterized.  Cauterization  should  be  performed  with  pure 
carbolic  acid  as  follows : 

A  swab  is  made  by  wrapping  a  small  wad  of  cotton  about 


IGO  MISCELLANEOUS  INJURIES 

the*  011(1  of  a  t()otli-j)k-k  or  match  and  (li|)])c(l  in  stroiii;-  car- 
bohf  acid  (])lienol).  Tiic  wound  is  then  sponged  (h'v  and  tlic 
carl)ohc  acid  carefully  a])j)licd  to  c\"cry  uook  and  cranny  in 
the  wound  area.  The  excess  carbolic  acid  is  immediately 
washed  away  by  pouring  alcohol  into  the  wnuiid.  A  sterile 
dressing  is  then  applied. 

If  carbolic-  acid  is  not  a\ailal)lc,  full  strciiuth  tincture  of 
iodin  may  be  used  to  swab  out  the  wound. 

Cauterization  with  an  iron  heated  to  a  reel  heat  has  been 
advised,  but  it  has  recently  been  abandoned  because  of  the 
extreme  pain.  Tt  is  justifiable  only  in  cases  where  the  animal 
is  known  to  be  suffering  from  hydroi)hobia. 

Hydrophobia. — Hydrophobia,  or  rabies,  is  an  acute  infec- 
tious disease  of  man  and  animals,  caused  by  a  specific  virus 
which  must  be  transmitted  through  an  abrasion  or  other 
wound  of  the  skin. 

Symptoms. — The  symptoms  are  depression  and  weakness, 
followed  by  convulsions  and  death.  The  old  idea  that  ani- 
mals suffering  from  rabies  feared  water  is  unfounded.  It 
arose  from  the  fact  that  animals,  during  the  convulsive  stage, 
are  imable  to  drink  water  because  attempts  at  drinking 
bring  on  cramps  of  the  throat.  These  same  con\'ulsive  cramp- 
like seizures  in  man  are  accompanied  by  a  gutteral  sound 
which  has  given  rise  to  the  belief  that  men  suffering  from 
this  disease  "bark  like  dogs." 

If  a  dog  is  suspected  of  having  ral)ies  it  should  ne\'er  be 
killed  until  it  has  been  shut  up  and  kept  under  obser\'ation 
for  at  least  a  week  or  ten  days.  If  the  dog  does  not  become 
sick  and  die  during  this  time  it  is  not  suffering  from  hydro- 
phobia. An  animal  with  disease  will  soon  liegin  to  show 
symptoms.  At  first  the  animal  is  simi)ly  sullen,  refusing 
food,  and  crawling  away  into  dark  corners.  When  callefl 
it  either  refuses  to  come  or  comes  after  several  commands 
and  soon  shrinks  out  of  sight.  During  this  i)eri()d  the  animal 
will  drink  water,  but  will  eat  little  or  nothing.  As  the  dis- 
ease progresses  there  are .  spasms  of  the  throat,  usually 
brought  on  by  attempts  to  drink,  and  later  the  animal 
becomes  excited,  running  about  and  snapi)ing  wildly  at 
friend  and  for.    In  this  stage  the  animal  will  rarely  turn  out 


BJTI'J    WOUNDS 


161 


of  its  path  to  l)ite  anyone.  Still  later,  general  convulsions 
and  death  occur. 

,  If  the  animal  has  already  been  killed  and  you  are  unde- 
cided whether  it  was  rabid  or  not,  the  entire  head  should 
be  removed  and  sent  to  the  health  authorities  for  examina- 
tion. The  diagnosis  can  be  made  from  examination  of  the 
brain. 

When  a  man  has  been  bitten  by  a  mad  dog  there  are 
never  any  symptoms  for  several  weeks  or  months  after  the 
injury.  This  allows  the  patient  time  to  wait  for  the  labor- 
atory report  on  the  condition  of  the  animal  before  taking  the 
treatment. 


Fig.  114. — Tooth  marks  made  by  snake  bites:  on  the  left  a  harmless  snake; 
fang-marks  in  the  center  and  on  the  right  indicate  a  poisonous  snake. 
(Ashhurst.) 


The  Pasteur  Treatment. — If  a  human  being  has  been  bitten 
by  a  dog  or  other  animal  known  to  have  hydrophobia, 
development  of  the  disease  may  almost  certainly  be  pre- 
vented by  the  Pasteur  treatment,  started  within  two  weeks 
after  the  injury.  The  treatment  consists  of  the  injection  of 
gradually  increasing  doses  of  the  virus  after  it  has  been  made 
much  less  powerful  by  prolonged  exposure  to  the  air.  The 
important  point  for  the  first-aid  worker  to  remember  is  that 
the  patient  must  be  sent  to  a  competent  physician  for 
treatment  not  later  than  ten  days  after  the  injury. 

Snake  Bite. — Whereas  hydrophobia  acts  through  an 
infectious  virus,  snake  bite  acts  by  the  direct  injection  of  an 
extremely  poisonous  fluid.  The  bite  of  a  snake  is  really  a 
U 


102  MISCELLANEOUS  INJURIES 

hypodoriiiic  injection,  t\\v  i)c)is()n  entering  tlie  blood  streiun 
throngh  tlie  small  i)nnetures  made  by  the  snake's  fangs. 

As  the  ])oisou  is  injected  through  a  groove  in  the  snake's 
fang,  rather  than  sim])l>'  l)y  the  saliva  covering  the  teeth, 
as  in  rabies,  the  clothing  gi\'es  nnich  less  protec-tion  than  in 
the  latter  case. 

Symptoms.  -The  poison  acts  \cr\'  rapidly,  tlu-  foot  or  hand 
beginning  to  swell  at  once;  general  symi)toms  develop 
within  a  few  minutes.  Collapse  and  unconsciousness  may 
quickly  residt. 

Treatment. — Most  of  the  treatment  must  be  given  by  the 
first-aid  worker.  There  is  rarely  o])portunity  to  secure  a 
physician  in  time  to  give  the  preliminary  treatment.  In 
the  first  place  an  improvised  tourniciuet  must  be  at  once 
applied  a  few  inches  above  the  wound.  This  stops  the  circu- 
lation and  prevents  the  rapid  spread  of  the  poison.  Next, 
the  wound  should  be  cut  widely  open  so  that  it  will  bleed 
freel\'  and  the  poison  sucked  from  the  wound.  This  is  not  a 
dangerous  procedure,  for,  if  not  swallowed,  only  a  small 
amount  of  poison  could  possibly  enter  the  system  from  the 
mouth.  Then,  if  materials  are  at  hand,  the  wound  should 
be  cauterized  with  pure  carbolic  acid  or  with  a  red  hot  iron 
and  left  open  so  that  bleeding  may  be  free.' 

It  has  been  shown  in  animals  that  the  dose  of  snake  \'cnoni 
which  caused  instant  death  could  be  borne  if  injected  beneath 
the  skin  in  small  fractional  doses,  given  ()^'er  a  i^eriod  of 
several  hours.  This  fact  is  taken  advantage  of  in  the  treat- 
ment of  snake  bite.  After  the  tourniciuet  has  been  in  jilace 
for  about  half  an  hour  it  is  loosened  for  a  few  minutes  and 
then  reapi)lied.  This  allows  a  little  poison  to  enter  the  sys- 
tem but  not  enotigh  entirely  to  overwhelm  the  })ody.  This 
is  repeated  at  intervals. 

I  )uring  this  time  the  treatment  of  shock  should  be  started 
and  stimulation  begun.  Small  doses  of  whisky  may  be  given 
to  sustain  the  system,  but  there  is  no  advantage  in  intoxica- 
tion, as  is  commonly  supposed. 

'  Mason's  Handbook  for  the  Hospital  Corps,  U.  S.  Army,  advises  the 
injection  of  permanganate  of  potash  in  2  per  cent,  solution,  hypodermically, 
in  the  vicinity  of  the  wound.     This  causes  decomposition  of  the  venom. 


BITE    WOUNDS  163 

Coffee  and  other  drinks  should  he  <^iven  in  larj^e  (|uanti- 
ties  to  increase  ehmination,  and  the  patient  kei)t  warm  hy 
the  use  of  blankets  and  hot-water  bags.  As  soon  as  the  pri- 
mary period  of  shock  has  passed,  a  dose  of  salts  should  be 
given  as  an  additional  aid  to  elimination.  If  the  patient 
lives  more  than  three  or  four  hours,  there  is  little  danger 
of  a  fatal  ending. 

After  recovery  begins,  the  injury  should  be  dressed  with  a 
wet  boric  acid  dressing  and  treated  as  an  infected  wound. 

Insect  Bites. — ^Insect  bites  or  stings  result  in  small  poi- 
soned wounds  which  may  be  very  painful.  The  bites  of  the 
tarantula  and  the  centipede  and  the  sting  of  the  scorpion 
are  especially  painful,,  but  are  rarely  dangerous  to  life. 
Surrounding  the  injury  there  is  an  area  of  swelling,  and,  in 
severe  cases,  there  is  considerable  shock. 

Treatment. — In  mild  cases  weak  ammonia  water  or  solu- 
tions of  bicarbonate  of  soda  should  be  applied  to  neutralize 
the  poison,  which  is  acid  in  reaction.  Following  this,  cold 
compresses,  mentholated  vaselin,  or  spirits  of  camphor  may 
be  applied  to  relieve  the  pain. 

In  severe  cases  the  wound  should  be  incised  with  a  sharp 
knife,  the  poison  squeezed  or  sucked  from  the  wound,  and 
the  wound  washed  with  weak  ammonia  or  other  alkaline 
solution.  Whisky  may  be  given  and  other  measures  taken 
to  prevent  shock.  After  the  first  symptoms  have  passed  a 
wet  dressing  may  be  applied  and  the  wound  treated  as  any 
other  infected  wound. 

Tetanus. — Tetanus  or  lockjaw  is  a  general  disease,  the 
result  of  wound  infection  with  the  tetanus  bacillus.  It  is 
especially  apt  to  occur  after  punctured  wounds  or  any  other 
wounds  where  dirt  is  carried  deeply  into  the  tissues.  The 
tetanus  bacillus  is  normally  found  in  the  intestinal  canal  of 
horses,  so  that  the  disease  is  prone  to  follow  wounds  con- 
taminated with  dirt  containing  horse  manure,  such  as  stable 
refuse,  cultivated  field  soil,  and  dirt  from  the  streets.  As 
the  bacillus  does  not  thrive  in  the  open  air,  tetanus  is  more 
apt  to  follow  deep,  punctured  wounds  where  the  air  is  not  in 
contact  with  the  deeper  parts  of  the  wound.  A  rusty  nail 
is  apt  to  cause  tetanus  because  the  rough  iron  is  likely  to 


104 


M  ISC  ELL  A  XEO I  '.S'   /  XJ  CRI ES 


earn'  iutVctod  niatorial  (k>c])lN'  iiitc)  the  tissues.    The  synip- 
tDins  tlo  not  occur  until  about  ci<rht  davs  or  longer  alter  the 


Fic.  115. — Tetanus  bacilli  in  negative  and  .spore  stage.     (Abbott.) 
(Magnified  about  1000  diameters.) 

injury.    Meanwhile,  the  woinid  is  a])])arently  healing-  kindly 
with  slight  or  no  evidences  of  infection.    The  first  symptoms 


Fiu.  116. — Convulsions  in  tetanus  occurring  on  the  tliini  (l:i\-  ut  the  disease. 
Notice  the  bending  backward  of  the  spine.      (Ashhurst.) 


noted  are  convulsions,  beginning,  as  a  rule,  in  the  muscles 
of  the  jaw.    The  comulsions  rapidly  spread  to  other  parts 


BITE   WOUNDS  105 

of  the  body,  the  patient  is  in  severe  pain,  strength  is  rapifliy 
lost,  and  death  usually  results  after  a  few  days.  A  few  eases 
recover. 

Treatment. — When  a  deep  wound  is  probably  contaminated 
with  refuse  from  stables  it  should  be  treated  as  though  it 
were  known  to  be  actually  infected  with  tetanus  bacilli. 

The  wound  should  be  widely  opened  with  a  sharp  knife, 
so  that  every  portion  of  it  is  exposed  to  the  air  and  the 
cavity  disinfected  with  strong  carbolic  acid  or  tincture  of 
iodin.  It  is  then  washed  out  with  peroxide  of  hydrogen, 
and  sterile  gauze  soaked  in  the  same  solution  is  packed  into 
the  wound.    The  packing  is  removed  and  reapplied  daily. 

In  all  such  cases  tetanus  antitoxin  should  be  secured  and 
injected  into  the  tissues  in  the  region  of  the  wound.  Conse- 
quently, even  if  the  wound  itself  is  apparently  trivial,  arrange- 
ments should  be  made  for  the  injection  of  tetanus  antitoxin 
with  the  least  possible  delay. 

Often  the  patient  is  not  seen  until  the  spasms  develop. 
The  jaws  are  stiff,  but  can  be  opened,  and  there  is  nervous- 
ness and  apprehension.  On  questioning  you  are  told  that 
there  was  a  small  wound  about  a  week  before.  Such  a  case 
should  be  sent  at  once  to  a  hospital,  where  large  doses  of 
antitoxin  may  be  given.  In  transporting  such  a  patient 
great  care  should  be  used  to  prevent  jars  which  may  initiate 
the  periods  of  convulsions.  If  possible  a  physician  should 
be  secured  first,  so  that  a  large  hypodermic  of  morphin 
may  be  given. 


CHAPTER  VII. 
GENERAL  INJURIES. 

SHOCK. 

Used  in  its  surgical  sense,  shock  is  a  term  ^\  hich  indicates 
a  condition  of  depression  of  the  nervous  system,  more  or 
less  profound. 

Shock  follows  injury,  and,  as  a  rule,  the  more  severe  the 
injury  the  greater  the  shock.  However,  this  is  not  neces- 
sarily true.  Some  patients  may  suffer  extensive  injuries  in 
a  railroad  or  machinery  accident  and  show  no  evidence  of 
shock,  while  another  patient  may  develop  marked  shock 
after  comparatively  insignificant  injuries. 

Symptoms. — The  symptoms  develop  slowly,  usually  begin- 
ning shortly  after  the  accident,  although  in  some  cases  they 
may  be  delayed  for  several  hours  or  longer  (secondary  shock). 
When  shock  is  fully  developed  the  observer  notices  that  the 
patient  is  either  unconscious  or  in  a  stupid  condition,  taking 
no  interest  in  his  surroundings.  The  face  is  pale  and  anx- 
ious, with  the  eyelids  drooping  and  the  eyes  dull  witli  dilated 
pupils.  The  breathing  is  feeble  and  shallow,  the  pulse  weak 
and  rapid,  the  skin  cold  and  clammy,  and  there  is  a  general 
feeling  of  bodily  and  mental  fatigue. 

Shock  is  more  apt  to  occur  under  the  following  conditions: 

1.  After  severe  injuries. 

2.  After  hemorrhage. 

3.  After  severe  mental  strain. 

4.  After  exhaustion  from  bodily  exertion,  ex]K)sure  or 
disease. 

There  are  two  elements  in  shock:  one,  the  physical  injury, 
and  the  other  the  mental  strain.  The  fact  that  it  may  fol- 
low comparatively  minor  injuries  has  already  been  noted, 
the  nervous  element  being  well  illustrated  by  the  fact  that 
some  patients,  who  are  doing  well,  go  into  shock  after  seeing 


SHOCK  167 

their  wound  dressed.  People  in  railway  wrecks  who  see 
many  horrible  sights  before  being  rescued  are  esi)ecially  apt 
to  suffer  from  shock. 

The  excitement  of  the  moment  may  delay  the  occurrence 
of  shock.  Thus  a  man  may  work  hard  for  hours  in  spite 
of  his  own  injuries,  rescuing  other  people,  bandaging  wounds, 
and  otherwise  making  himself  useful,  only  to  develop  shock 
after  the  period  of  excitement  is  over.  It  sometimes  happens 
that  an  accident  occurs  a  long  distance  from  help  and  the 
patient  must  walk  miles  before  securing  assistance.  In  such 
cases  exhaustion  increases  the  possibility  of  shock. 

The  character  of  the  injury  may  also  determine  the  occur- 
rence of  shock.  For  instance,  shock  is  much  less  common 
after  injuries  such  as  a  clean-cut  amputation  of  a  leg  than 
after  crushing  injuries  of  the  foot. 

Severe  or  long-continued  pain  increases  shock.  Thus, 
there  is  less  danger  when  the  pain  of  a  broken  arm  is  pre- 
vented by  the  use  of  suitable  splints  than  whenthe  patie  nt 
is  obliged  to  walk  with  the  arm  dangling,  every  step  causing 
great  pain.  Morphin,  because  it  diminishes  pain,  tends  to 
prevent  shock. 

Treatment. — Bearing  in  mind  what  has  just  been  said  it 
is  evident  that  treatment  should  begin  with  the  removal  of 
the  causes  which  may  aggravate  shock.  Hemorrhage  should 
be  stopped,  the  patient  should  be  removed,  if  possible,  from 
the  immediate  vicinity  of  the  accident  and  measures  should 
be  taken  to  relieve  the  pain. 

However,  only  temporary  dressings  or  splints  should  be 
applied.  We  are  unjustified  in  taking  a  long  time  to  apply 
a  splint  when  the  patient  is  in  a  marked  state  of  collapse. 
Indeed,  in  severe  injuries  it  is  often  wiser  to  carry  out  the 
treatment  on  the  spot  than  to  attempt  removal  before  there 
are  signs  of  reaction. 

Place  the  patient  in  a  horizontal  position  with  the  head 
slightly  lowered.  Cover  him  well  with  blankets  to  preserve 
the  body  heat,  and  apply  hot-water  bottles  to  the  feet, 
abdomen,  and  to  the  sides  of  the  chest.  Glass  bottles  filled 
with  hot  water,  hot  bricks,,  or  any  other  form  of  heat  will 
serve.     Heat  may  be  applied  internally  by  the  use  of  hot 


IGS  GEXERAL   IX JURIES 

drinks.  es])eciall,\'  colVeo  or  beef  tea,  and  l\v  tlie  use  of  hot 
water  or  eotVee  injected  into  the  reetiun.  It'  a  thernionieter 
is  available  the  temperature  of  the  injected  fhiid  sliould  be 
about  110°  F.,but  if  no  thermometer  is  at  hand  the  fluid 
may  be  tested  by  poiu'ini;'  it  on  the  skin  of  the  forearm. 
It  should  feel  comfortably  warm  but  not  biu"nin<i;  hot. 

Stiiuulation  may  be  given  in  addition  to  the  other  treat- 
ment. Aromatic  spirits  of  ammonia,  in  ten-drop  doses  every 
fifteen  minutes  for  four  doses,  and  whisky  or  brandy,  in  tea- 
sjjoonful  doses  every  five  or  ten  minutes  for  five  or  six  doses, 
are  suitable  stinudants.  Large  doses  of  alcoholic  drinks 
should  not  be  given.  Coffee,  because  of  the  cafi'ein  which  it 
contains,  is  one  of  the  best  stimulants. 

If  this  treatment  is  successful  the  s^inptoms  gradually 
become  less  marked,  the  pulse  is  stronger,  the  l)reatliing  is 
easier,  and  the  general  appearance  is  impro^'ed.  The 
period  of  shock  may  last  only  a  few  minutes  or  it  may  last 
for  days.  Even  when  early  reaction  occurs  it  is  better  to 
keep  the  patient  warm  and  cpiiet  for  a  while  to  prevent 
the  recurrence  of  shock. 

FAINTING. 

Fainting,  or  syncope,  is  caused  by  lack  of  blood  in  the 
brain.  It  resembles  shock  except  that,  as  a  rule,  there  is 
only  a  trivial  injiuy  or  none  at  all. 

A  ])ers()n  may  faint  after  a  very  slight  injiu-y,  such  as  a 
pin-prick  or  a  comparatively  slight  blow;  after  an  unpleasant 
mental  impression,  such  as  fright  or  the  receipt  of  unpleasant 
news;  after  seeing  something  un])leasant,  as  the  sight  of 
blood  or  a  wound;  and  when  weak  and  exhausted,  as  after 
illness  or  severe  muscular  exertion.  Fainting  is  more  apt 
to  occur  in  hot,  crowded  places,  as  theatres  or  churches, 
than  in  the  open  air. 

If  the  above  is  carefully  read  and  its  relation  to  shock 
considered  it  will  be  noted  that  fainting  residts  from  many 
of  the  same  causes  as  shock.  The  essential  dilVerence  seems 
to  be  that  in  shock  there  is  more  or  less  general  depression, 
while  fainting  is  a  circulatory  disturbance  of  the  brain — a 
condition  of  anemia  of  the  brain. 


FAINTING  169 

The  condition  is  ushered  in  by  a  sensation  of  weakness 
and  exhaustion.  Everyone  recognizes  what  it  means  to  feel 
faint  which  only  differs  in  degree  from  complete  syncope. 
If  the  patient  is  watched  the  face  is  seen  to  grow  pale,  and 
it  is  apparent  that  he  is  taking  little  interest  in  his  surround- 
ings. When  questioned  he  is  apt  to  answer  at  random  or  not 
at  all.  The  breathing  is  shallow  and  the  pulse  is  either  very 
slow  or  very  weak.  Often  it  is  impossible  to  detect  the 
beating  of  the  pulse  at  the  wrist.  As  the  condition  develops, 
unconsciousness  occurs  and  the  patient  falls  limp  to  the 
floor. 

While  fainting  is  more  common  among  women  it  may 
occur  in  men.  I  have  seen  healthy  medical  students  fall  by 
twos  and  threes  at  the  mere  sight  of  a  particularly  bloody 
operation,  and  I  have  frequently  seen  strong  men  faint  dur- 
ing the  dressing  of  a  small  wound.  However,  both  men  and 
women  are  more  prone  to  faint  after  an  illness  or  period  of 
exhaustion,  either  physical  or  mental.  Some  persons  have 
the  fainting  habit,  those  who  faint  once  being  apt  to  faint 
repeatedly. 

Treatment. — ^When  the  first  sensation  of  faintness  occurs, 
complete  syncope  can  often  be  avoided  if  the  patient  is  gi^en 
a  glass  of  water  and  allowed  to  stand  by  an  open  windlw. 
When  more  active  measures  are  necessary  it  is  a  good  jman 
to  place  the  patient  in  a  chair,  with  the  body  bent  forward, 
the  head  being  held  between  the  knees.  This  accomplishes 
two  things:  it  places  the  head  lower  than  the  heart  and 
allows  the  blood  to  run  mto  the  brain,  and  it  squeezes  together 
the  contents  of  the  abdomen,  forcmg  the  blood  from  the 
large  abdominal  veins  into  the  general  circulation.  Try 
this  yourself  and  notice  how  this  position  held  for  a  minute 
or  two  will  cause  flushing  of  the  neck  and  face. 

If  unconsciousness  has  already  occurred  the  patient 
should  at  once  be  placed  flat  on  his  back  with  the  head  low, 
preferably  lower  than  the  rest  of  the  body.  Never  hold  a 
fainting  person  upright  under  any  circumstances.  In  ordi- 
nary cases  the  horizontal  position  is  all  that  is  required, 
recovery  soon  taking  place;  still,  the  position  should  be 
continued  for  a  few  minutes  so  that  recoverv  may  be  com- 


170  GEXERAL  IXJrniES 

plete.  Watfli  to  see  if  paleness  occurs  on  standing.  If  it 
does  there  is  dan<]:er  that  the  condition  may  recur  and  further 
treatment  be  required. 

In  addition  to  the  above,  for  mild  cases  and  to  prevent 
recurrence,  stimulants  may  be  given  by  mouth.  Aromatic 
spirits  of  ammonia,  whisky  or  brandy,  ice-water,  or  hot 
cott'ee  may  be  given.  Cold  sponging  of  the  face  and  chest 
and  inhalations  of  smelling  salts  are  additional  aids. 

Persons  subject  to  fainting  spells,  when  there  is  no  disease 
of  the  heart,  may  obtain  relief  and  diminish  the  attacks  by 
daily  cold  sponging  of  the  chest  and  face  and  by  exercises' 
to  strengthen  the  heart  and  bloodvessels.  When  psychic 
influences,  such  as  the  sight  of  an  operation,  cause  faintness, 
it  is  possible  to  school  oneself  by  repeatedly  being  present 
at  oi)erations,  and  thus  overcoming  the  tendency  to  faint, 
and  by  taking  the  sitting  position  outlined  above  when  the 
first  feeling  of  faintness  occurs.  Once  conquered  the  condi- 
tion is  not  apt  to  recur. 

SUNSTROKE. 

When  one  is  exposed  to\the  rays  of  the  sun  or  to  extreme 
heat  the  tendency  is  tow^ard  an  increase  of  the  internal 
temperature  of  the  body.  ,  Thus  a  temperature  of  100°  F. 
in  very  hot  weather  is  not  Uncommon  and  has  no  special  sig- 
nificance. The  normal  lops  of  heat  is  increased  through 
increased  perspiration  and  the  rise  of  temperature  does  not  be- 
come excessive.  The  mechanism  which  causes  the  dilatation 
of  the  siu'face  vesssels  and  increased  perspiration  is  under 
the  control  of  the  brain  and  nervous  system. 

After  prolonged  exposure  to  the  sun  the  nerves  which  con- 
trol this  regulation  become  exhausted,  with  the  result  that 
the  temperature  of  the  body  gradually  rises,  in  severe  cases 
rising  as  high  as  110°  to  112°  F.  This  condition  is  known  as 
heatstroke  or  sunstroke.     The  higher  temperatures,  unless 

'  One  of  the  best  exercises  to  cure  the  fainting  habit  consists  in  bending 
forward  so  the  outstretched  hands  nearly  touch  tlie  ground,  and  lioiding 
this  position  until  the  face  is  shghtly  flushed.  Then  stand  erect  and  repeat 
this  movement  fifteen  to  twenty  times. 


SUNSTROKE  171 

rapidly  counteracted,  result,  in  a  short  time,  in  unconscious- 
ness and  death. 

Symptoms. — ^The  attacks  may  be  preceded,  for  several 
hours  or  even  two  or  three  days,  by  certain  warning  signs  or 
symptoms,  such  as  muscular  weakness  and  fatigue,  nausea, 
a  sensation  of  weakness  in  the  pit  of  the  stomach,  headache, 
and  dimness  of  vision. 

As  these  symptoms  become  more  marked  they  may  merge 
slowly  or  rapidly  into  a  state  of  unconsciousness.  The  face 
is  flushed,  the  pupils  are  dilated,  the  skin  is  hot  and  dry, 
the  breathing  is  labored,  and  the  pulse  overactive.  The 
temperature  (taken  in  the  rectum  or  armpit  if  the  patient  is 
unconscious)  is  always  considerably  above  normal. 

Prevention. — During  very  hot  weather  the  activities  should 
be  decreased,  especially  for  a  few  hours  around  midday. 
Most  of  the  work  should  be  done  in  the  early  morning  and 
the  late  afternoon,  resting  during  the  hottest  part  of  the 
day. 

The  clothing  should  be  cool  and  loose,,  preferably  light  in 
color,  because  white  reflects  the  heat  while  black  absorbs  it. 
When  in  the  direct  rays  of  the  sun  the  head  should  be  shaded 
by  a  light,  well-ventilated  hat.  Indoors  the  temperature  of 
the  air  may  be  reduced  by  means  of  evaporation,  such  as  is 
obtained  by  the  use  of  wet  sheets  hung  near  the  windows 
and  doors,  the  room  being  kept  well  ventilated  by  electric 
fans. 

The  diet  should  contain  little  meat  and  few  sweets.  It 
should  be  light  and  unstimulating.  Cool  water  should  be 
drunk  freely  and  frequently,  but  alcoholic  drinks  should  be 
taken  only  in  great  moderation.  Cold  sponging  and  cool 
baths  may  be  frequently  taken.  Warm  and  hot  baths,  con- 
trary to  the  common  belief,  do  not  make  one  cooler,  and 
should  be  avoided  in  very  hot  weather. 

It  is  hardly  necessary  to  add  that  persons  already  weak- 
ened by  disease  or  exhaustion  must  take  special  precautions 
to  avoid  sunstroke. 

Treatment. — If  seen  during  the  earlier  period  before  the 
temperature  is  high  or  unconsciousness  is  present,  it  may  be 
sufficient  to  allow  the  patient  to  rest  in  the  shade,  bathing 


172 


GEXERAL   IXJUHIES 


the  lie;i<l.  chest  and  wrists  in  cold  water  and  iiivin^  a  ]i<i;ht 
stiinuhiiit  such  as  aromatic  aimnonia  or  cold  collee. 

Ill  more  severe  cases  where  unconsciousness  is  present  the 
patient  should  be  strip])ed  and  put  to  bed,  wrapped  in  a 
sheet  wet  with  cold  water  and  kept  wet  by  frequent 
si>rinkliug  with  ice-water.  If  a  clinical  thermometer  is 
a\ailable,  the  cold  pack  (or  cold  bath)  should  be  continued 
until  the  temperature  is  below  103°  ¥.  Otherwise  it  is  con- 
tinued initil  the  jxatient  becomes  conscious  and  the  skin 
feels  cool. 


Fig.  117. — Showing  the  applicatinn  of  a  cold-waUr  roil  in  the  treatment  of 
sunstroke  or  other  forms  of  congestion  of  the  Ijraiii.     (Hare.) 

An  ice-cap  to  the  head,  cool  drinks,  and  massajiie  of  the 
body  during  the  cooling  process,  are  all  valuable  adjuncts 
to  treatment. 

The  cold  pack  must  not  be  too  long  continued  or  the  tem- 
perature may  be  reduced  considerably  below  normal.  After 
it  is  stopped,  watch  the  i)atient  carefully.  Jf  the  Hushing 
of  the  face  retin-ns  and  the  temperature  rises,  the  cold  i)ack 
should  again  be  started,  but  if  the  patient  remains  })ale 
with  a  normal  or  subnormal  tcmi:)(M-ature  and  a  weak  and 
rapid  pulse,  he  is  evidently  sull'cring  from  the  secondary 
effects  of  the  injury  to  the  nerves  and  rccpiircs  treatment 


HEAT  EX  JI A  U.ST  J  ON  173 

to  prevent  seeondary  shock.     I)urin<^  this  staj^e  it  may  be 
necessary  to  apply  external  heat. 

After  the  immediate  effects  of  the  sunstroke  have  passed 
off  the  patient  shoukl  be  kept  at  rest  for  several  days  until 
recovery  is  complete  and  sliould  avoid  prolonged  exposure 
in  the  sun  for  several  months. 


Fig.  lis. — Giving  a  patient  a  cold  bath  for  sunstroke  with  special  square 
bath  tub  and  stretcher.     (Hare.) 


HEAT   EXHAUSTION. 

This  condition  occurs  as  a  result  of  working  in  a  heated 
atmosphere,^  especially  when  the  physical  or  mental  powers 
are  exhausted  or  depressed. 

Symptoms. — The  symptoms  differ  from  those  of  sunstroke 
and  are  more  those  of  exhaustion.  The  face,  instead  of  being 
greatly  flushed,  is  pale  or  only  slightly  flushed,  and  the  skin 
is  moist  and  may  be  cool.    The  temperature  is  not  increased 

1  This  condition  is  very  common  in  the  heated  boiler  pits  of  ocean  steamers, 
in  factory  firemen  and  in  soldiers  marching  in  hea^-y  clothes  or  accouter- 
ments.  It  often  occurs  in  the  hot  dry  climate  of  Mexico  and  Arizona  where, 
owing  to  the  rapid  evaporation  of  perspiration,  sunstroke  is  uncommon. 


174  GENERAL  I XJ CRIES 

and  the  pulse  is  rapid  and  weak.     l\Miipnrary  uiiconscious- 
noss  may  occur. 

Treatment. — As  this  couihtioii  is  more  in  the  nature  of 
syncope,  or  fainting;,  the  ai>i)Hcation  of  cold  is  unnecessary. 
The  patient  should  be  laid  horizontally  in  a  cool  i)lace  and 
given  cool  drinks  and  mild  stinudation.  Stokers  who  are 
brought  to  deck  unconscious  are  usually  able  to  return  to 
work  within  a  few  hours. 

EXPOSURE  TO  EXTREME  COLD. 

The  treatment  of  the  depression  due  to  exposure  to  extreme 
cold  has  already  been  given  in  the  discussion  of  frost-bite. 
It  may  be  notetl  that  the  general  treatment  is  practically  the 
same  as  the  treatment  of  shock. 

UNCONSCIOUSNESS. 

I'liconsciousness,  or  coma,  is  a  state  in  which  the  patient 
is  entirely  oblivious  of  his  surroundings.  lie  is  imable  to 
answer  when  spoken  to  and  cannot  be  aroused.  In  some 
cases  the  condition  is  only  partial,  that  is,  he  may  be  aroused, 
but  soon  becomes  unconscious  when  let  alone.  This  latter 
condition  is  called  incomi)lete  unconsciousness  or  semi- 
unconsciousness.  A  person  asleep  is  not,  properly  speaking, 
unc(Miscious,  because  he  may  be  awakened  by  ordinary 
means. 

There  is  no  other  condition  which  causes  the  first-aid 
worker  so  much  trouble  as  unconsciousness.  It  may  result 
from  so  many  different  diseases  that  it  is  often  difficult  even 
for  a  physician  to  decide  upon  the  cause. 

We  have  already  seen  that  the  state  may  be  induced  by 
shock,  fainting,  sunstroke,  heat  prostration,  snake  bite, 
hydrophobia,  tetanus,  and  exposure  to  cold.  In  addition 
it  may  be  due  to  alcoholism,  to  head  injuries,  to  apoplexy, 
to  epilepsy,  asphj'xiation  (drowning  or  gas  poisoning),  to 
nephritis,^  to  hysteria,  and  to  many  poisons  and  acute 
diseases. 

•  Unconsciousness  due  to  nephritis  (kidney  disease)  occurs  in  the  hite 
stages  and  is  known  as  uremia  or  uremic  coma. 


ilNCONSCIO  USNE>S>S  175 

In  emergency  eases  tlie  following'  conditions,  in  the  order 
of  their  frequency,  are  the  most  often  seen:  fainting,  alcohol- 
ism, epilepsy,  head  injuries,  nephritis,  and  as})hyxiation. 
As  it  is  so  difficult  to  determine  the  cause,  it  is  well  to  ado])t 
a  plan  of  treatment  which  will  be  suitable  for  all  cases  until 
the  cause  can  be  determined. 

First  lay  the  patient  upon  his  back  and  loosen  the  clothing 
about  the  neck.  hAamine  first  to  determine  the  presence  of 
asphyxiation,  hemorrhage,  sunstroke  or  poisoning,  for  these 
conditions  demand  immediate  treatment.  If  there  is  no 
evidence  of  any  of  these,  note  the  pulse  and  the  appearance 
of  the  face.  If  the  face  is  pale  and  cold  the  head  should  be 
placed  lower  than  the  body  and  stimulation  given.  If 
the  face  is  flushed  the  head  should  be  raised  slightly  and 
cold  cloths  applied  to  the  forehead.  Give  the  patient  plenty 
of  fresh  air  and  loosen  the  clothing  over  the  chest  so  as  to 
allow  free  breathing. 

While  you  are  doing  this  send  for  a  physician  and  learn 
from  the  bystanders  or  from  friends  as  much  as  you  can 
regarding  the  onset  of  the  condition.  The  symptoms  of  the 
patient  and  the  surroundings  will  enable  you  to  exclude 
some  of  the  conditions  mentioned;  thus  sunstroke  and 
freezing  belong  only  to  the  extremes  of  temperature. 

The  history  of  a  fall  or  blow  would  point  to  a  brain  injury 
which  could  be  confirmed  by  examination  of  the  head  for 
bumps  or  wounds.  Asphyxiation  is  at  once  evident  if  the 
respiratory  action  is  watched. 

If  unconsciousness  is  not  the  result  of  an  accident,  find  out 
if  the  patient  has  been  drinking  or  has  complained  of  being 
sick.  Whether  the  period  of  unconsciousness  started  with  a 
convulsion  (epilepsy,  uremia,  tetanus,  strychnin  poisoning), 
or  after  a  more  or  less  prolonged  period  of  illness  (sunstroke, 
acute  disease,  etc.). 

If  you  are  unable  to  determine  the  probable  cause  of  coma, 
you  must  treat  the  symptoms  rather  than  the  disease.  If 
the  body  is  cold  and  the  face  pale,  give  stimulants,  apply 
external  heat,  and  cover  with  blankets;  but  if  the  face  is 
flushed  and  feels  warm,  stimulation  and  external  heat  is 
unnecessary. 


170  aEXKh'Al.   J.WJi'h'IES 

P>xamino  for  injury,  notice  tlie  odor  of  tho  ])reatli,  and 
search  for  sijjns  of  heniorrliaije.  If  tlie  l)reatlun<^  stoi)s, 
bef:;in  artificial  resijiration  and  keep  it  up  until  the  jjliysician 
arrives. 

Hysterical  Unconsciousness.  This  condition  is  the  result 
of  a  functit)nal  disorder  of  the  ner\"ous  system.  The  i)atient, 
usually  a  woman,  falls  to  the  jjround  apparently'  uncon- 
scious, but  the  fall  is  not  so  heedless  or  sudden  as  to  result 
in  injury.  Often  there  is  no  ascertainable  cause  for  the  attack. 
^^ometimes  it  is  brought  on  by  a  friyht  or  emotional  shock. 

The  face  appears  normal  in  appearance,  the  eyes  are 
closed  but  the  lids  are  trenudous  and  attempts  to  oj)en  the 
eyes  are  resisted.  The  eyeballs  are  rolled  upward  and  the 
pupils  are  normal.  The  ])ulse  is  normal  but  the  res})iration 
is  greatly  disturbed,  possibly  slow  and  dee])  or  very  shallow 
and  rai)id.  The  Ixxly  may  be  limp  or  held  rigid.  If  the  hand  is 
pinched  or  pain  caused  in  any  other  manner  the  part  is  with- 
drawn but  the  patient  can  seldom  be  made  to  speak  or  cry 
out.  In  short,  the  entire  appearance  is  that  of  a  person  who 
is  "faking"  for  some  unknown  cause. 

"When  the  physician  arrives,  patients  of  this  tyi)e  are  sur- 
rounded by  a  crowd  of  sympathizers  who  are  rubbing  the 
wrists  and  dashing  cold  water  in  the  face  and  otherwise 
causing  a  great  commotion.  In  some  cases  there  are  con- 
vulsive movements  of  the  arms  and  legs  (hysterical 
convulsions) . 

Treatment. — While  the  unconsciousness  is  nt)t  a  true  coma, 
yet  it  is  due  to  a  loss  of  nerve  control  and  should  not  be 
treated  as  ordinary  malingering.  The  patient  should  be 
left  with  one  unexcitable  attendant,  who  should  not  give 
any  treatment,  but  should  speak  quietly  and  firmly  and 
attempt  to  help  the  patient  gain  control  of  herself.  The 
usual  result  is  that  after  a  few  minutes  recovery  is  complete. 
In  cases  which  persist  for  some  time,  the  o])inion  of' a  physi- 
cian should  be  secured.  Even  among  ])hysicians  cases  are 
occasionally  AATongly  diagnosed  as  hysteria,  later  a  more  or 
less  serious  complaint  being  foimd  which  was  previously 
entirelv  overlooked. 


CHAPTER   VOL 
SUFFOCATION. 

Suffocation,  or  asphyxiation,  is  that  form  of  unconscious- 
ness which  is  due  to  the  shutting  off  of  the  supply  of  oxygen 
to  the  hnigs.  In  some  cases  the  obstruction  to  the  entrance 
of  air  into  the  lungs  is  mechanical.  This  occurs  in  constric- 
tion of  the  neck  by  hanging  or  choking,  in  obstruction  of  the 
windpipe  by  a  foreign  body,  and  the  obstruction  of  the 
mouth  and  nose  with  sand  or  dirt  or  other  similar  material. 

In  other  cases  asphyxiation  occurs  as  the  result  of  the 
attempts  to  breathe  air  too  poor  in  oxygen.  This  is  seen 
most  frequently  in  high  altitudes  and  in  deep  mines.  In 
mines  the  air  is  usually  tested  with  the  miner's  lamp.  When 
the  lamp  ceases  to  burn  it  is  recognized  that  the  air  is  not 
fit  to  breathe. 

A  similar  result  is  seen  in  attempts  to  breathe  air  mixed 
with  other  gases.  The  gas  may  cause  asphyxiation  because 
it  displaces  the  air  from  the  room  or  it  may  be  itself  poi- 
sonous. For  example,  illuminating  gas  illustrates  both  of 
these  principles;  it  is  poisonous  of  itself  and  at  the  same 
time  displaces  the  ordinary  air. 

In  drowning,  or  suffocation  in  falling  sand  or  dirt,  there 
is  practically  no  available  air,  so  that  breathing  stops 
immediately. 

A  rather  unusual  accident  has  been  described  which  illus- 
trates a  rare  method  of  asphyxiation:  A  man  nearly  buried 
in  a  tunnel  cave-in  was  buried  in  dirt  and  gravel  up  to  his 
neck,  but  his  head  was  above  ground.  Here,  although  sur- 
rounded by  an  abundance  of  air,  he  was  unable  to  breathe 
because  the  weight  of  the  dirt  and  sand  prevented  the 
inspiratory  movement  of  the  chest. 
12 


178 


SUFFOCATION 


Treatment,  lu  the  tivatuuMit  of  asphyxiation  there  are 
three  steps  whieh  must  be  carrii'd  out: 

1.  The  cause  of  sufl'oeatlou  nuist  he  removech 

2.  Artificial  respiration  must  l)e  ))ei:;uu. 

3.  Accompany iuij;  injuries  and  shock  nnist  recei\e  ai)pro- 
priate  treatment. 

Prcliniinari/  Trcdfmcnf.-  The  first  thinu'  to  do  is  to  remo\e 
the  obstruction  to  l>reathing.  Patients  should  be  taken 
from  the  water  when  drowning";  carried  from  the  smoky 
atmosi)here  in  suffocation  by  smoke;  foreifin  bodies  should 
be  remoNed  from  the  mouth;  and  air-tight  clothing  and 
constricting  bands  removed  from  the  neck. 


Fig.  111*. — .Vrtificial  respiration  \)\  Scluicfcr's  inctluul.  ]5.v  tliis  iiieaii.s 
fluids  and  mucus  are  more  readily  expelled  fruni  the  upper  respiratory 
tract  than  in  the  older  methods.     (Hare.) 


When  this  is  done,  if  breathing  has  ceased,  artificial 
respiration  should  be  begun  at  once.  Suffocation  is  one  of 
the  few  emergencies  in  which  a  great  deal  depends  upon 
the  speed  in  which  the  remedial  measin-es  are  carried  out. 
While  artificial  respiration  is  being  ])crformed,  an  assistant 
can  be  sent  for  dry  clothing,  blankets,  stimulants,  or  for 
other  remedies  which  may  be  required,  depending  on  the 
nature  of  the  injury. 


A  RT I  Fir  I A  L  liKHI'I  II A  TION  179 

ArfificiaJ  Rcsjjiration. — Artificial  respiration  consists  in 
movement  of  the  chest  by  a  second  person  in  imitation 
of  the  normal  respiratory  movement.  Of  the  different 
methods  of  artificial  respiration,  the  following  three  methods 
are  the  most  widely  known.  The  first  is  one  of  the  best  because 
it  can  be  performed  by  one  person  and  can  be  carried 
out  over  a  long  period  with  the  minimum  amount  of  fatigue. 

The  details  of  the  methods  of  artificial  respiration  are  as 
follows : 

Schaefer  Method. — 1 .  The  patient  is  placed  face  downward 
upon  the  floor  or  ground,  with  the  arms  stretched  out  above 
the  head^  and  the  face  turned  to  one  side,  so  that  there  is  no 
hindrance  to  the  entrance  of  air  into  the  nose  or  mouth. 
As  the  tongue  is  apt  to  drop  backward  it  should  be  drawn 
outward  by  inserting  one  finger  in  the  mouth  and  hooking  the 
tongue  forward. 

2.  Kneel  astride  the  subject's  thighs;  rest  the  palms  of 
your  hands  over  the  muscles  of  the  small  of  the  back,  the 
fingers  spread  over  the  lower  ribs  on  each  side. 

3.  With  the  arms  held  stiff,  swing  forward  slowly  so  that 
the  weight  of  your  body  is  gradually  but  not  violently 
brought  to  bear  upon  the  patient's  back.  If  you  try  this 
on  a  friend  you  will  notice  that  this  movement  forces  the 
air  from  the  chest.  Immediately  swing  backward,  releasing 
the  weight  from  the  chest,  which  expands  because  its  natural 
elasticity  allows  the  air  to  rush  into  the  lungs. 

4.  Repeat  this  complete  movement  about  fifteen  times  a 
minute;  that  is,  repeat  the  forward-and-backward  movement, 
which  represents  a  complete  respiration,  every  four  or  five 
seconds. 

5.  Continue  these  movements  until  the  patient  breathes 
naturally  or  until  a  physician  arrives.  If  no  physician  can 
be  obtained  keep  up  the  artificial  respiration  without 
interruption  for  at  least  an  hour. 

When  natural  breathing  returns  try  to  time  the  move- 
ments to  the  natural  breathing.  It  is  permissible  to  stop 
occasionally  for  a  few  seconds  to  see  if  the  natural  respira- 
tory movements  are  returning. 

^  Id  some  cases  the  arms  may  be  bent  and  placed  at  the  sides  (Fig.  119). 


180 


SUFFOCATION 


The  Siilirfftcr  Method. — In  this  the  i)ationt  is  ])liiced  iii)on 
his  hack  with  a  pad  beneath  his  shoulders  and  the  operator 


,^  &■ 

/ 

^^ 

1.' 

> 

#^^ 

^ 

Fig.  120. — Sylvester's  method  of  artificial  respiration.     ]'"irst  inovcmeiit: 
the  patient's  arms  are  placed  at  right  angles  to  the  trunk,   the  elbows  resting 

on  tlic  flour,  to  expand  or  inflate  the  chest.      (Hare.) 


Fig.  121. — Sylvester's  method  of  artificial  respiration.  Second  movement: 
the  patient's  arms  are  drawn  toward  the  physician,  in  order  to  expand  the 
chest  still  further.     (Hare.) 

kneels  above  his  head.  After  seeinj,^  that  the  mouth  is  free 
and  that  the  tongue  has  not  fallen  back,  the  movements  are 
as  follows: 


ARTIFICIAL  RESPI RATION 


181 


1.  The  arms  are  grasped  near  the  el})ows  and  drawn  well 
up  above  the  head  (inspiration).  1'hey  are  held  here  for 
about  two  seconds  (Figs.  120  and  121). 


Fig.  122. — Sylvester's  method  of  artificial  respiration.  Third  movement: 
the  patient's  arms  are  raised  and  the  elbows  approximated  to  contract  the 
chest. 


Fig.  123. — Sylvester's  method  of  artificial  respiration.  Fourth  movement: 
the  patient's  elbows  and  forearms  are  pressed  forcibly  upon  the  floating  ribs 
to  expel  the  air  from  the  chest. 


2.  The  arms  are  brought  do\Miward  so  that  the  elbows 
are  against  the  chest  and  firm,  steady  pressure  is  made.    This 


1S2  SUFFOCATION 

nioveiiUMit  forces  the  air  out  of  the  chest  (ex])iratlon)  (Fisjjs. 
122  ami  123). 

These  movements  should  he  contimu-d  ahout  fifteen  times 
a  minute;  that  is,  a  complete  inspiration  and  exi)iration 
every  four  seconds.  Time  yourself  if  i)ossil)le  while  doinji; 
this,  for,  in  the  excitement  the  mo\ement  is  apt  to  he  hui'ricd 
and  much  too  fast. 

The  chief  disadvantajie  of  this  movement  is  that  the 
tongue  may  dro])  hack  and  act  as  an  imjx'dimcnt  to  resi)ira- 
tion.  An  assistant  should  watch  constantly  to  he  sure  that 
this  does  not  occur.  In  addition,  this  method  involves  much 
harder  work  for  the  operator  than  the  Schaefer  method. 
If  the  movements  are  to  be  kept  up  for  a  long  time,  the 
oi)erator  must  he  "spelled"  by  a  third  person  or  the  easier 
method  must  be  chosen. 

Man'hall  IlalFs  Method. — In  this  method  the  patient  is 
placed  on  the  floor  or  ground  with  the  face  downward,  his 
forehead  resting  on  one  arm  and  a  roll  of  clothing  supporting 
his  chest.  While  in  this  position  the  weight  of  the  body 
compresses  the  ribs  and  expels  the  air  from  the  chest — an 
artificial  expiration  which  is  increased  by  making  pressure 
on  the  lower  ribs.  Then  the  operator,  with  one  hand  on  the 
j)atient's  free  arm  near  the  shoulder  and  the  other  imder  or 
in  front  of  the  corresponding  hip-bone,  rolls  the  body  to  the 
side  and  a  little  beyond.  An  assistant  aids  in  this  move- 
ment by  handling  the  head  and  the  underlying  arm.  When 
the  body  has  been  thus  rolled  somewhat  more  than  half- 
way round,  the  chest  becomes  relie\ed  from  superincumbent 
weight  and  a  certain  volume  of  air  enters.  After  resting  a 
second  or  two  in  this  attitude  of  inspiration,  the  patient  is 
returned  to  the  prone  position  and  pressure  made  along  the 
ribs  to  imitate  the  expiratory  act. 

Merhaniral  Rr.H].iruti()n. — During  recent  years  two  mechan- 
ical respirators  ha\'e  been  put  on  the  market  (the  lung 
motor  and  the  pulmotor).  Both  of  these  work  on  the  prin- 
ciple of  a  pump,  to  which  is  attached  a  tube,  on  the  end  of 
which  is  a  mouth-piece  so  made  as  to  fit  closely  over  the 
j)atient's  mouth.  When  the  pumj)  has  been  adjusted  to  the 
patient's  lung  cai)acity  the  mouth-piece  is  placed  over  the 


A  HTIFIC/A  L  HESri  RA  TION 


183 


patient's  mouth  and  air  f()rcil)ly  pumped  in  and  drawn  out 
of  the  lungs.  These  maclvines  are  much  better  than  the  man- 
ual methods,  but  are  seldom  availal>le  when  required. 

The  choice  of  a.  method  of  artificial  respiration  depends 
on  the  condition  of  the  patient,  the  number  of  assistants, 
and  the  strength  of  the  operators.    The  first  is  the  easiest 


Fig.  124. — The  lungmotor.  One  of  the  machines  used  for  mechanical  artifi- 
cial respii'ation :  A,  volume  gauge  slide  pin;  P,  pointer  for  gauge  slide  pin;  E, 
inspiration  cylinder;  C,  oxygen  inlet;  Z>,  air  inlet;  B,  air  and  oxygen  mixing 
valve;  H,  expiration  cylinder;   T,  tubing;  M,  mouth-piece. 


to  apply.  The  two  latter  are  a  little  more  efficacious  when 
sufficient  assistants  are  at  hand.  There  is  no  objection  to 
changing  from  one  method  to  another,  when  the  movements 
must  be  continued  for  a  long  time.  If  natural  breathing 
returns  and  then  ceases,  begin  artificial  respiration  again. 
When  consciousness  returns,  give  the  patient  hot  coffee  or 
hot  beef  tea,  and  massage  the  arms  and  legs  toward  the  heart 


IS-t  SUFFOCATION 

as  an  aid  to  tlie  circulation.  Tlicn  carry  him  to  slielter  where 
he  can  rest  (inieti>'  in  a  warm  hed  for  several  hours.  Use 
other  methods  for  the  i)revention  of  shock. 

CHOKING. 

Chokini;  may  result  from  constriction  about  the  neck  or 
from  foreign  bodies  in  the  windpi])e.  The  first  rc(iuirement 
is  the  removal  of  any  obstruction.  In  adults  a  foreiji;n  body 
can  often  be  remo\'ed  from  the  windpipe  by  a  sharp  blow 
u])on  the  back,  wliich  causes  a  sudden  ex])ulsive  movement, 
("hildren  can  be  i)ickcd  up  by  the  heels  and  lield  head  down- 
ward to  dislodge  a  small  particle  which  has  been  drawn  into 
the  windpipe  or  throat.  If  this  is  not  successful,  and  the  for- 
eign body  is  in  the  back  part  of  the  throat,  it  may  sometimes 
l)e  dislodged  by  means  of  the  finger  introduced  into  the 
mouth. 

In  patients  who  are  suffering  from  alcoholism  or  other 
form  of  poisoning,  as  well  as  those  unconscious  from  drown- 
ing or  electric  shock,  the  tongue  may  fall  })ack  so  as  to  shut 
off  the  windpipe.  Always  examine  for  this  condition  in  any 
unconscious  patient  who  is  having  difficulty  in  ])reathing, 
and,  if  present,  draw  the  tongue  do\Miward  with  the  finger 
inserted  in  the  mouth. 

When  the  throat  is  clear  and  there  are  no  constricting  bands 
about  the  neck,  respiration  should  be  resumed  at  once.  If 
the  patient  does  not  begin  to  breathe  immediately,  artificial 
respiration  should  be  begun  without  delay. 

DROWNING. 

The  first  step  necessitates  the  removal  of  the  drowning 
person  from  the  water.  This  requires  an  expert  knowledge 
of  swimming  and  the  various  methods  of  supporting  a  drown- 
ing person  in  the  water.  It  is,  of  course,  useless  to  jump  into 
deep  water  unless  you  are  able  to  swim. 

When  a  person  falls  overboard,  immediately  throw  a  life- 
preserver,  or  chair,  or  some  other  object  that  will  float  into 
the  water  and   immediatel\'  summon  help.     Do  not  jump 


DROWNING  185 

into  the  water  yourself  unless  you  .arc  an  expert  swimmer. 
There  have  been  cases  where  valuable  time  has  been  lost 
because'  the  rescuing  party  has  had  to  go  to  the  assistance  of 
the  would-be  rescuer,  himself  badly  in  need  of  help. 

The  only  instance  in  which  an  indifferent  swimmer  is  justi- 
fied in  jumping  into  the  water  is  in  case  a  child  or  other 
helpless  person  has  fallen  in.  In  such  case  be  sure  to  grasp 
some  object  which  will  float  so  that  the  additional  support 
will  be  at  hand. 

On  reaching  the  drowning  person,  be  careful  not  to  allow 
him  to  draw  you  under.  Swimming  instructors  advise  hit- 
ting a  panic-stricken  person  with  the  fist  and  partially  stun- 
ning him.  Support  the  drowning  person  by  grasping  him 
by  the  hair  or  clothing  and  holding  him  with  the  mouth  and 
nose  just  above  water  until  help  arrives. 

Only  an  expert  swimmer  can  tow  a  drowning  person,  even 
a  small  child,  to  the  shore. 

Remove  the  body  from  the  water  at  once  and  begin  treat- 
ment on  the  spot  except  in  very  cold  weather  when  it  is 
permissible  to  move  the  patient  to  shelter  if  it  is  near. 

It  is  difficult  to  say  how  long  the  patient  may  be  submerged 
without  death  resulting.  Apparently  authentic  cases  have 
been  reported  in  which  the  rescued  person  was  revived  after 
several  hours  under  water.  However,  this  is  so  improbable 
that  the  accuracy  of  the  observation  may  be  questioned.  It 
is  certain  that  submersion  for  more  than  five  minutes  is 
very  apt  to  be  fatal.  On  the  other  hand,  recovery  has  resulted 
in  innumerable  cases  where  the  patient  was  apparently  dead. 
Consequently  artificial  respiration  should  always  be  resorted 
to,  except  in  persons  known  to  have  been  under  water  for 
an  hour  or  longer. 

The  steps  to  be  taken  in  the  resuscitation  of  a  drowned 
person  are  as  follows: 

1.  Removal  of  wet  seaweed  and  debris  from  the  mouth. 
This  is  accomplished  by  the  introduction  of  the  finger  into 
the  back  of  the  throat. 

2.  Removal  of  water  from  the  lungs.  The  patient  is 
placed  face  downward  on  the  ground  and  then  lifted  by  plac- 
ing the  hand  beneath  the  abdomen  so  that  the  head  hangs 


180 


SUFFOCATION 


(lowinvanl.     This  allows  \vluite\or  water  is  ])r('stMit    to  run 
out  of  the  mouth. 

3.  Artificial   respiration   hy   oi\e   of   the    methods    already 
described. 


Fig.  125 


Figs.  125  and  120. — Method  of  raisiujj;  the  Ijody  of  a  i^aticnt  just  removed 
from  the  water  to  allow  the  water  to  run  out  of  the  luii^.s.      (Burnham.) 


4.  The  restoration  of  the  body  heat.  This  can  be  done  by 
the  use  of  warm  blankets  and  other  forms  of  external  heat. 

After  breathinfi  retm-ns  the  patient  should  be  ])ut  to  bed, 
and    given    warm    drinks    and    stiimilants.      Pneumonia    or 


ASPIIYXIAriON  BY  ILLUMINATfNO  GAS         187 

bronchitis  may  follow  from  the  irritation  of  the  inspired 
water  so  that  it  is  advisable  to  keep  the  patient  in  bed  for 
several  days  after  the  accident. 

SUFFOCATION   BY    SMOKE. 

In  rescuing  a  person  from  a  room  filled  with  smoke  a 
moist  cloth  placed  over  the  mouth  will  make  the  smoke 
much  less  irritating.  It  should  also  be  remembered  that 
near  the  floor  the  smoke  is  less  dense  than  at  a  higher  level, 
so  that  one  may  be  able  to  crawl  where  it  is  impossible  to 
walk.  Fill  the  lungs  with  fresh  air  before  entering  the  room 
and  work  as  quickly  as  possible  while  in  the  smoky 
atmosphere. 

When  the  rescued  person  is  not  unconscious  it  usually 
requires  only  a  few  minutes  in  the  fresh  air  to  revive  him. 
When  unconsciousness  is  complete  begin  artificial  respira- 
tion as  soon  as  possible  after  reaching  the  open  air.  In 
addition,  sprinkle  cold  water  in  the  patient's  face  and  give 
stimulants  as  soon  as  consciousness  returns. 

The  irritation  of  the  smoke  is  apt  to  cause  bronchitis  and 
pneumonia.  Consequently,  it  is  advisable  to  keep  tbe  patient 
quiet,  preferably  in  bed,  for  several  days  after  the  accident. 

ASPHYXIATION   BY   ILLUMINATING    GAS. 

The  ordinary  form  of  gas  asphyxiation  is  carbon  mon- 
oxide poisoning,  which  is  most  frequently  seen  in  poisoning 
with  the  ordinary  illuminating  gas.  The  condition  comes 
on  slowly,  unconsciousness  often  occurring  without  warning. 

There  are  apt  to  be  preliminary  headache,  dizziness,  and 
throbbing  of  the  head  in  the  presence  of  the  escaping  gas. 
Ringing  in  the  ears  and  spots  before  the  eyes  may  occiu-, 
but  usually  all  the  symptoms  are  so  mild  that  they  pass 
unnoticed. 

In  illuminating  gas  poisoning  unconsciousness  occurs 
early.  During  this  stage  the  lips,  skin,  and  nails  take  on  a 
bluish  tinge,  the  heart  becomes  rapid  and  weak  and  the 
respiration  shallow  and  irregular,  finally  ceasmg  entirely. 

While  the  above  refers  to  illuminating  gas  poisoning  the 


188  SUFFOCATION 

symptoms  and  treatment  are  very  similar  in  ])ois()ninc;  witli 
gas  from  eoal  fires,  sewer  gas,  mine  gas,  and  poisoning  from 
so-called  "back  draught"  at  fires  where  the  air  is  laden  with 
carbon  monoxide  as  a  result  of  incomplete  combustion. 

Treatment. — Never  take  an  open  light  of  any  sort  into  a 
room  filled  with  gas,  as  the  gas  may  become  ignited,  resulting 
in  a  dangerous  explosion.  Before  entering  a  room  filled  with 
gas  take  two  or  three  deep  breaths  of  fresh  air  and  then  hold 
the  breath  until  the  \\indow  is  reached.  Open  the  window 
widely  or  break  the  glass  if  it  does  not  oi)en  I'asily.  Take 
another  deep  breath  of  fresh  air  at  the  open  window  and  then 
search  the  room  for  persons  overcome  by  the  gas.  (^irry  the 
first  person  found  to  the  open  air  and  return  yoiu'self,  or 
send  someone,  to  open  the  remaining  ^\in(lo^^■s,  if  there  are 
any,  and  to  make  a  carefid  search  for  other  \'ictims. 

On  one  occasion  I  was  called  to  attend  a  mother  and  child, 
overcome  with  gas,  and  on  arri\'ing  I  found  a  second  child 
unconscu)US  in  an  adjoining  room,  who  had  been  completely 
overlooked. 

\Yhen  open  air  is  reached,  the  respiration  of  the  patient 
should  be  carefully  observed,  and,  if  weak  or  absent,  artificial 
respiration  should  be  started.  If  the  patient  is  able  t(^ 
swallow,  hot  coffee  or  other  stimulant  should  be  given  at 
once. 

The  unconsciousness  of  gas  poisoning  is  dilf erent  from  other 
forms  of  suffocation.  When  the  open  air  is  reached  the  patient 
may  revive  rapidly,  or  unconsciousness  may  continue  or  even 
grow  deeper.  This  is  because  in  carbon  monoxide  (illuminat- 
ing gas)  poisoning  the  blood  undergoes  a  permanent  change 
which  diminishes  its  power  to  absorb  oxygen.  Patients  are 
sometimes  seen  who  remain  unconscious  for  days  as  a  result 
of  illuminating  gas  poisoning.  Recovery  after  these  long 
periods  of  unconsciousness  is  very  rare. 

After  respiration  has  begun,  means  should  be  taken  to 
remove  the  patient  to  the  nearest  hospital,  where  expert 
medical  attention  may  be  secured.^     If  this  is  not  to  be 

1  The  modern  treatment  of  carbon  monoxide  poisoning  depends  mainly 
upon  the  transfusion  of  blood,  a  surgical  procedure  which  consists  in  the 
introduction  of  healthy  blood  into  the  bloodvessels  of  the  patient. 


ASPHYXIATION  BY  IlililTANT  (JASES  189 

obtained  tlie  treatment  must  ])o  confined  to  rest  in  })ed  in  a 
well-aired  room,  combined  witli  the  administrati(^n  of  nour- 
ishment and  stimulants  when  the  patient  is  able  to  swallow. 

ASPHYXIATION   BY   IRRITANT    GASES. 

In  asphyxiation  by  irritating  gases,  such  as  bromin, 
chlorin,  or  formalin,  the  chief  efi'ect  is  an  intense  inflamma- 
tion of  the  eyes,  nose,  throat,  and  lungs.  At  first  this  makes 
breathing  difficult.  Later  the  inflammation  may  cause  bron- 
chitis and  pneumonia  severe  enough  to  result  in  death. 

In  America  these  cases  are  seen  only  in  workers  in  chemi- 
cal factories,  but  in  the  European  war  such  gases  have  been 
used  extensively  in  oft'ensive  and  defensive  operations.  For 
this  reason  the  following  official  report  is  published  in  full. 
While  the  report  contains  many  technicalities,  it  is  thought 
better  to  publish  it  as  it  stands  rather  than  to  attempt  to 
modify  it  in  any  way. 

Asphyxiation  by  Gas  in  the  European  War.^  —  Chlorin  or 
bromin  gas,  compressed  into  liquid  form  and  liberated 
from  large  metal  tanks  when  the  wind  is  blowing  toward  an 
opposing  trench,  has  caused  very  distressing  deaths  when 
inhaled  in  concentrated  form.  Being  heavy  gases  they  hug 
the  ground,  moving  to  leeward,  and  sink  into  the  trenches. 
The  first  effect  is  to  cause  the  eyes  to  water,  and  this  is 
quickly  followed  by  a  violent  irritation  of  the  bronchial  tract. 
If  troops  are  unprotected  and  remain  in  the  trenches  they  rap- 
idly develop  a  capillary  bronchitis,  with  a  hypersecretion  of 
thin  watery  mucus,  which  fills  up  the  air  spaces  of  the  lungs 
and  practically  causes  death  from  drowning.  Those  receiv- 
ing concentrated  doses  died  in  from  one  to  tliree  hours, 
sometimes  from  edema  of  the  glottis,  but  principally  from 
exhaustion  of  the  heart  in  trying  to  pump  the  blood  thi-ough 
the  engorged  capillaries  surrounding  the  bronchioles  and 
ultimate  air  spaces  of  the  lungs.  This  suffocating  process 
sometimes  lasts  from  one  to  three  days,  the  younger  men 
with  stronger  hearts  holding  out  longer  than  the  older. 

1  Surgn.  A.  M.  Fauntleroy,  U.  S.  Navy:    Report  on  the  Medico-Military 
Aspects  of  the  European  War. 


190  SrFFOCATlOX 

Tlu>  mortality  from  this  t'orm  of  sull'ocation  depends  on 
tlu'  degree  of  eoiieentration  of  the  j^as  inhaled  antl  the  age 
of  the  patient.  Man\'  eases  have  been  mild  on  account  of 
the  capricious  action  of  tlie  wind  in  distrihuting  the  gas 
along  the  trenches,  some  parts  of  tlu'  Hne  receiving  it  in 
more  concentrated  form  than  others.  This  results  in  all 
stages  of  an  asphyxiating  bronchitis,  from  the  grave  cases 
which  are  cyanosed  and  gasping  for  breath  to  those  suffering 
from  a  mild  form  of  irritation  of  the  bronchioles.  On  this 
account  some  recover  (piickly  and  others,  lingering  for  a 
longer  ])eri()d,  slowly  regain  the  normal,  not  infrecpiently 
exhibiting  more  or  less  marked  evidence  of  bronchiectasis. 
The  postmortem  examinations  of  the  lungs  show  them  to  be 
about  four  times  their  normal  weight,  with  an  enormous 
dilatation  of  the  air  spaces,  which  latter  arc  filled  with  a  thin, 
watery,  and  sometimes  blood-streaked  nnicus. 

Treatment. — As  regards  treatment,  those  in  the  open  air 
seem  to  sutler  less.  Oxygen  gas,  administered  slowly,  unques- 
tionably gives  relief.  Atropin,  hypodermically,  is  used  for 
the  overdistended  right  heart,  while  the  lateral  prone  position 
of  the  patient  favors  drainage  of  the  lung  fluid. 

By  far  the  most  important  is,  of  course,  the  prophylactic 
use  of  some  form  of  combined  helmet  and  respirator,  which  is 
intended  not  only  to  render  the  gas  innocuous  but  also  to 
protect  the  eyes.  When  the  gas  was  first  used  it  came  as  a 
surprise  and  there  were  many  more  victims  than  at  present. 
There  are  a  number  of  different  types  of  protecting  masks 
in  use,  all  having  for  their  object  the  neutralization  of  the 
gas  when  inhaled  through  the  mask  or  helmet.  Ex])erience 
has  taught  that  to  be  effective  the  protecting  apparatus 
must  either  be  in  the  form  of  a  helmet  entirely  covering  the 
head  and  tucked  in  at  the  neck,  or  in  the  form  of  a  mask 
fitted  siuigly  around  the  face  under  the  chin  and  over  the 
front  part  of  the  cap  above  the  \'is()r,  by  means  of  strong 
elastic  tape.  The  mask  or  helmet  should  be  made  of  some 
impermeable  material,  such  as  mackintosh,  with  a  piece  of 
transi)arent  celluloid,  about  <S  inches  long  by  o  inches  wide, 
sewn  into  corresponding  elongated  oN'al  ()i)ening  cut  in  the 
mask  opposite  the  eyes.    That  part  of  the  mask  in  front  of 


ASPHYXIATION  BY  llilUTANT  GASES  101, 

the  nose  and  moutli  is  punctured  })y  al^out  twenty-five  small 
round  openings  arranged  in  the  form  of  a  square.  Behind 
these  openings,  inside  the  mask,  a  slightly  larger  square 
piece  of  cloth,  also  punctured  with  holes,  is  sewn  so  as  to 
form  a  pocket  for  a  little  pad,  impregnated  with  chemicals, 
which  is  slipped  into  the  pocket  just  before  the  mask  is  to 
be  used. 

The  pad  in  this  form  of  protector  is  about  4  inches  long 
by  3  inches  wide  and  contains  an  equal  quantity  of  hypo- 
sulphite and  bicarbonate  of  soda,  distributed  equally  through- 
out the  pad  by  a  few  loose  stitches  holding  the  sides  of  the 
pad  together.  When  the  protector  is  to  be  used,  about  one 
ounce  of  water  is  poured  on  the  pad  from  a  small  bottle,  the 
latter  kept  in  the  soldier's  coat  pocket  for  that  purpose, 
and  the  pad  is  then  slipped  into  the  pocket  of  the  mask  just 
before  the  latter  is  adjusted. 

The  first  forms  of  masks  consisted  simply  of  gauze  or 
oakum,  saturated  with  the  chemicals  and  secured  around 
the  mouth  and  nose.  This  did  not  protect  the  eyes,  which 
quickly  became  irritated,  so  that  it  was  impossible  to  keep 
them  open  for  long  when  the  gas  was  concentrated.  This 
of  course,  prevented  the  soldier  from  fighting  in  the  presence 
of  gas.  It  was  also  thought  that  it  complicated  matters  by 
having  the  chemicals  in  solution  beforehand,  whereas  in  the 
form  of  mask  described  above  it  was  only  necessary  to  pour 
water  on  the  pad  before  using.  Several  of  these  pads  are 
furnished  with  each  mask,  to  be  kept  in  a  tin  box  in  the 
pocket  along  with  the  small  vial  of  water.  The  mask  form 
of  protector  is  thought  to  be  much  more  practicable  in  that 
it  is  not  as  disagreeably  hot  as  the  helmet  form,  and  can  be 
secured  above  the  visor,  when  not  in  use,  thereby  making  it 
more  easily  accessible  at  all  times.  Masks  containing  a  pad 
saturated  with  lime-water  or  turpentine  have  also  been  used. 

Not  infrequently  the  gas  may  be  seen  from  some  distance 
as  a  thin  greenish-yellow  cloud,  and  it  is  ofttimes  possible 
to  detect  the  odor  for  an  appreciable  time  before  it  becomes 
concentrated,  thereby  giving  sufficient  warning  to  allow  the 
mask  to  be  adjusted  in  time  to  meet  the  oncoming  gas. 

Flame  projectors  (flamenwerfer)  are  used  by  the  Germans 


192  SUFFOCATION 

for  tlirowina;  buriiliiu;  Ii(jui(ls.  T1k\\'  arc  nctv  iniic-li  like  tlie 
ordinary  i)ortal)le  Hrc  cxtiuu'iiislu'r  in  construction,  tlirowing 
a  liquid  which  at  once  catches  fire  s})outaneously,  and  has 
an  effective  range  of  thirty  meters  (about  ninety-four  yards). 
The  burns  caused  by  this  method  are  of  the  deep  sloughing 
variety,  exj)osing  tendons  and  bone,  and  arc  treated  with 
wet  dressings  until  healthy  graiuilations  ai)i)car.  These 
flame  projectors  are  mainly  emjiloycd  in  street  and  house- 
to-house  fighting,  although  their  use  in  the  trenches  has 
been  reported  a  nimiber  of  times.  Hand  grenades  (bombs) 
and  shells  l^n'c  recently'  been  employed  at  short  range  to 
})r()duce  an  irritating  and  asi)hyxiating  gas  on  bursting. 
Although  intended  to  render  portions  of  the  trenches  unten- 
able, reports  from  the  front  indicate  that  their  action  is  very 
variable  and  much  influenced  by  the  presence  of  the  wind. 
The  necessarily  small  quantity  of  gas  that  is  involved  at  the 
time  of  bursting  has  a  ver^'  restricted  local  cliect. 


CHAPTER   IX. 

REGIONAL  INJURIES. 

Various  injuries,  with  the  exception  of  fracture,  have  been 
discussed  generally,  without  regard  to  their  occurrence  in 
special  locations.  Certain  injuries  in  one  location  take  on 
special  characteristics  which  may  not  be  present  in  the  same 
injury  in  other  parts  of  the  body.  Thus,  hemorrhage  from 
a  wound  of  the  hand  requires  entirely  different  treatment  from 
hemorrhage  from  the  nose  (nosebleed) .  In  the  following  pages 
the  various  injuries  will  be  classified  under  the  different 
regions  of  the  body  and  the  discussion  largely  limited  to  the 
special  methods  of  treatment  that  are  required.  While  the 
treatment  is  indicated  in  each  case  it  is  not  intended  that, 
as  outlined  here,  it  should  be  regarded  as  entirely  complete. 
Each  case  should  be  considered  in  its  relation  to  the  general 
discussion  of  the  subject  in  the  preceding  pages. 

'     HEAD. 

Wounds  of  the  Scalp. — Because  of  the  abundant  blood 
supply,  wounds  of  the  scalp  bleed  freely.  The  hemorrhage 
can  usually  be  stopped  by  applying  a  compress  and  making 
pressure  with  the  fingers  directly  over  the  wound.  In  some 
cases  where  the  bleeding  is  especially  profuse  it  may  be  stopped 
by  tying  a  narrow  bandage  tightly  about  the  head  just  above 
the  ears.  Naturally  the  wound  should  be  swabbed  out  with 
tincture  of  iodin  or  other  antiseptic,  as  has  been  outlined  in 
the  chapter  on  Wounds. 

In  every  case  of  scalp  wound,  be  on  the  lookout  for  frac- 
ture of  the  skull  or  injury  to  the  brain.    It  is  always  advis- 
able to  keep  the  patient  quiet  in  bed  for  several  hours  after 
every  severe  blow  on  the  head. 
13 


194  REGIONAL  INJURIES 

Treatment. — If  a  i)hysiciau  cannot  be  obtained,  shave  the 
hair  from  the  scalp  for  abont  an  inch  on  each  side  of  the 
wonnd,  cleanse  the  wound  and  hold  the  edges  togetlu>r  with 
adhesi\e  ])laster. 

Infection  of  the  Scalp. — Occasionally  after  insignificant 
injuries  w  hich  have  been  neglected,  and  even  after  wounds 
sntnred  by  skilled  surgeons,  infection  may  develo])  and 
s])read  ra])i(lly  beneath  the  scalp.  This  is  shown  by  increased 
throbbing  pain  and  swelling  of  the  scalp.  The  swelling  is 
not  marked  but  is  evident  only  through  a  slight  thickening 
of  the  snrroimding  scalp  which,  very  characteristically, 
"pits"  on  pressin-e — that  is,  when  the  finger  is  remo\'ed  after 
firm  pressure  a  pit  is  left  \\hich  does  not  disappear  for  some 
minutes. 

Treatment. — This  condition  is  very  serious  and  recjuires 
attention  ■\\'ithin  a  few  hours.  When  no  surgeon  is  avail- 
al)le  the  woimd  should  be  opened  widely  by  cutting  the 
sutures  and  o])ening  the  cavity  of  the  wound,  so  that  any 
retained  pus  may  escape.  If  the  wound  is  small  the  crust 
should  be  removed  with  a  sterile  pair  of  scissors  or  a  sharp 
tooth-pick,  previously  dipped  in  iodin.  In  any  case  a  large 
wet  boric  acid  dressing  should  be  applied. 

Concussion  of  the  Brain. — This  condition  results  from 
se\'ere  blows  and  falls  upon  the  head.  It  is  supposed  to  be 
due  to  a  jarring  or  shaking  of  the  brain,  and  the  patient  is 
said  to  be  stunned  or  knocked  senseless.  Temporarily  the 
brain  ceases  to  functionate.  The  ])atient  is  dizz\',  confused, 
nauseated,  pale,  and  sometimes  unconscious.  The  pulse  is 
rapid  and  weak  and  the  respiration  is  irregular. 

If  the  condition  is  limited  to  simple  concussion  the  period 
of  insensibility  lasts  for  only  a  few  minutes.  However,  such 
after-efi'ects  as  headache,  weakness,  and  nausea  may  last 
for  some  time. 

Treatment. — ]Most  cases  recover  consciousness  after  a  few 
minutes'  rest,  but  they  should  be  kept  at  rest  for  several 
hours  in  a  quiet  darkened  room,  the  head  and  shoulders 
slightly  elevated.  If  they  show  symptoms  of  shock,  heat 
should  be  applied  to  the  body  and  an  ice-cap  placed  upon  the 


HEAD 


195 


head.    Stimulants   should   be   given  cautiously  in  cases  of 
head  injuries. 

Intracranial  Injury.  In  iDany  cases  after  a  blow  on  the 
head  the  symptoms  are  more  severe,  indicating  a  more 
serious  injury  to  the  brain.  If  the  brain  is  pressed  upon  })y  a 
fragment  of  a  bone,  as  occasionally  happens  in  fracture  of 
the  skull,  or  if  a  small  vessel  inside  the  skull  bleeds  and  the 
escaped  blood,  confined  within  the  bony  cavity,  causes 
pressure  on  the  brain,  the  result  is  known  as  compression  of 


Fig.  127.- 


-Perforating  bullet  wound  of  the  head  with  wound  of  exit  showing 
brain  protrusion.     (Park.) 


the  brain.  In  more  severe  cases  the  brain  substance  may  be 
torn  and  severely  injured,  this  condition  being  known  as 
laceration  of  the  brain.  These  conditions,  together  with 
concussion,  are  sometimes  spoken  of  as  intracranial  injury, 
a  rather  loose  diagnosis  which  indicates  simply  that  the  brain 
has  been  injured,  without  designating  the  particular  type  of 
injury  present. 

After  a  blow  on  the  head  the  first-aid  worker  is" interested 
chiefly  in  deciding  whether  there  have  been  any  serious  conse- 


196 


REGION  A  L  I  .\J  URI ES 


qiicnces  or  wliether  the  condition  is  sini])U'  concussion  which 
will  (juickly  i)ass  away. 

In  most  hospitals  it  is  made  a  standini;'  I'ulc  to  keep  every 
head  injury  under  observation  for  several  hours,  to  lie  cer- 
tain that  no  serious  injury  is  present. 

Symptoms. — ^^''he  mildest  cases  show  only  concussion  with 
symptoms  which  clear  up  within  a  few  minutes.  INIore 
severe  cases  show  the  symptoms  of  ordinary  concussion 
which,  instead  of  clearinu;  up,  persist  for  several  hours. 
These  cases  should  be  watched  very  closely  for  evidences 
of  compression  of  the  brain. 


Fig.  128. — Cross-section  of  the  head  showing  hemorrhaKe  between  the  skull 
and  brain,  a  result  of  a  blow  on  the  skull  without  fracture.     (Ashhurst.) 


If  the  injury  to  the  skull  results  in  the  rupture  of  a  blood- 
vessel in  the  brain  the  patient  at  first  shows  symptoms  of 
concussion  which  may  entirely  disappear  within  a  few  min- 
utes. As  the  torn  vessel  slowly  bleeds,  the  escaped  blood, 
held  within  the  firm  bony  cavity  of  the  skull,  causes  gradu- 
ally increased  pressure  which  makes  itself  evident  in  uncon- 
sciousness, deep  stertorous  respiration,  irregular  heart  action, 
and  possibly  death.  This  is  known  as  "compression  of  the 
brain,"  and  is  very  similar  to  apoplexy.  If  the  hemorrhage 
in  the  brain  is  from  a  very  small  vessel  the  secondary  symp- 


EYE  197 

toms  of  compression  may  not  occur  for  several  hours  after 
the  injury. 

In  laceration  of  the  brain,  unconsciousness  occurs  at  once 
and  lasts  for  a  long.  time.  The  intermediate  stage  of  complete 
consciousness  is  practically  never  present. 

If  a  patient  has  received  a  head  injury  he  should  be  kept 
at  rest  as  outlined  under  Concussion  and  watched  for  symp- 
toms which  might  indicate  serious  injury  to  the  brain. 

If  the  patient  grows  slowly  more  and  more  stupid  and 
unresponsive,  or  if  semiconsciousness  or  unconsciousness  occur 
after  a  preliminary  stage  of  clearness,  there  is  almost  cer- 
tainly hemorrhage  within  the  skull.  If  there  is  vomiting,  a 
slow  pulse,  or  persistent  headache,  the  condition  is  less  cer- 
tainly, but  possibly,  present. 

Unequal  pupils,  convulsions,  or  paralysis  of  an  arm  or 
leg  are  bad  symptoms  when  they  occur.  If  any  of  these 
symptoms  occur  after  a  blow  on  the  head,  even  if  the  injury 
is  apparently  insignificant,  it  is  best  to  secure  the  services 
of  a  physician. 

Treatment. — ^The  treatment  consists  of  rest  in  bed,  with 
the  head  and  shoulders  slightly  elevated,^  an  ice-cap  being 
applied  to  the  top  of  the  head.  The  body  should  be  kept 
warm  and  hot  drinks  may  be  given.  Stimulants  should 
rarely  be  given  to  a  patient  suffering  from  head  injuries. 


EYE. 

Contusion  of  the  Eye. — A  blow  in  the  eye  results  in  the 
ordinary  "black  eye,"  the  discoloration  being  caused  by 
bleeding  beneath  the  skin.  Because  the  skin  about  the  eye- 
lids is  very  loose  there  may  be  considerable  hemorrhage  from 
a  very  slight  blow.  The  dark  color  of  the  blood  in  the  tis- 
sues (ecchymosis)  persists  for  about  two  weeks,  that  is, 
until  the  ecchymosis  is  entirely  absorbed. 

Treatment. — ^The  treatment  consists  in  the  application  of 
cold  compresses  or  cold  water  immediately  after  the  blow  is 


1  A  convenient  method  of  securing  elevation  is  that  of  placing  blocks  under 
the  head  of  the  bed  so  that  it  is  elevated  about  8  to  10  inches. 


198 


RECIOXAL   IXJI'IUES 


received.  After  the  seeoiul  day  hot  ai)])hcati()ns  wliich  tend 
to  hasten  ahsorptioii.  are  preferable. 

Wounds  about  the  Eye. — These  are  apt  to  be  associated 
with  profuse  heinorrhaue.  Stronp;  antiseptics  should  be 
avoided  because  of  the  danger  of  injury  to  the  eye.  Boric 
acid  in  saturateil  solution  is  a  non-irritatiuii;  antisei)tic  which 
may  be  applied  freely. 

Foreign  Body  in  the  Eye. — Small  specks  of  dirt  and  sand 
may  be  blown  into  the  eye.  ITuless  they  rest  directly  on  the 
cornea'  there  is  ^•ery  little  pain.  After  a  foreign  body  has 
been  in  the  eye  for  a  few  hours  the  entire  eye  api)ears 
congested  antl  inflamed. 


Fig.  129. — Method  of  lioldinn  the  upiter  lid  tvinipd  back  in  scarcliiu^  for  a 
foreign  body.      (Vcasey.) 

Treatment. — Never  rub  the  eye,  because  this  only  serves 
to  increase  the  irritation.  Blo\nng  the  nose  or  winking 
rapidly  is  the  simplest  method  of  removing  a  foreign  body. 
If  this  is  not  successful,  grasj)  the  eyelashes  on  the  upper 
lid,  draw  the  upper  lid  downward,  so  that  the  lashes  of  the 
lower  lid  sweep  the  inner  surface  of  the  upper  lid.  Or  get 
the  patient  in  a  good  light  and  draw  the  lower  lid  downward, 
looking  carefully  for  the  speck,  especially  at  the  inner  end 
of  the  eye.     If  it  is  not  found,  turn  the  u])i)er  lid  backward 


'  The  front  ijart  of  the  eyeball  tlirough  wliich  the  light  passes. 


EARS 


199 


over  a  match  or  a  small  stick  and  look  on  the  inner  surface 
of  the  upper  lid.  If  you  are. still  unable  to  see  the  foreign 
body,  it  is  better  to  send  the  patient  to  a  physician.  If  the 
body  is  found  it  may  be  lightly  brushed  away  with  a  swab 
made  by  wrapping  a  little  cotton  aroimd  the  end  of  a  match, 
or  with  the  corner  of  a  handkerchief.  The  inflammation 
which  remains  after  the  particle  is  removed  requires  fre- 
quent irrigation^  with  boric  acid  solution.  If  very  severe, 
compresses  wet  with  boric  acid  should  be  applied. 

EARS. 

Boxer's  Ear. — After  a  blow  on  the  ear  there  is  sometimes 
a  hemorrhage  beneath  the  skin  which  may  make  the  ear 


Fig.  130. — Boxer's  ear.     (Posey  and  Wright.) 


several  times  its  normal  thickness.    The  swelling  is  apt  to 
remain  permanently,   and,   as   it   is  common   among   prize 

^  To  irrigate  the  eye  the  head  is  tipped  back  and  the  solution  dropped 
into  the  eye  with  a  medicine  dropper.  If  an  eye  cup  is  available  the  solu- 
tion may  be  poured  into  the  cup  which  is  applied  to  the  eye,  the  head  being 
then  tipped  backward  and  the  eye  winked  rapidly  in  the  solution. 


200  .  nECIOXAL   IX JURIES 

fighters,  it  has  been  termed  "boxer's  ear."  When  it  first 
t)ecurs  a  firm  bandage  should  be  a})])hed  o\er  a  n)tt()ii  com- 
press so  as  to  hmit  the  amount  of  swelUng. 

Foreign  Body  in  the  Ear.--(1iil(hvn  frequently  ])ush 
matcl'.cs,  beans,  beads,  and  other  small  bodies  into  the  ears. 
Flies  and  other  insects  may  crawl  into  the  ear  during  sleep. 

If  an  insect  gets  into  the  ear  it  causes  a  loud  buzzing, 
which  is  most  uncomfortable.  If  a  lighted  candle  is  held 
just  outside  the  ear  while  the  j^atient  is  in  a  room  otherwise 
dark  the  insect  will  freciiiently  crawl  out  towartl  the  light. 
Or  warm  water  may  be  dropped  into  the  ear,  drowning  the 
insect  and  stopping  the  buzzing.  After  the  buzzing  has 
st()i)})ed  the  ear  may  be  gently  syringed  with  warm  water, 
which  may  finally  remove  the  insect.  Other  o})jects,  such  as 
l)eads  which  do  not  swell,  may  be  removed  in  the  same 
way,  but  be  careful  not  to  wet  pieces  of  wood,  or  beans,  or 
similar  objects,  as  they  will  swell  and  cause  severe  pain. 

Never  try  to  pick  a  foreign  body  out  of  the  ear  with  a 
yi'in  ov  other  instrument.  Such  attempts  only  ])ush  the  body 
farther  in  and  may  cause  permanent  injury  to  the  ear  drum. 

NOSE. 

Foreign  Body  in  the  Nose. — A  foreign  body  in  the  nose 
may  sometimes  be  remo^■cd  by  blowing  the  nose  ^'iolentl3' 
or  by  sneezing.  A  sneeze  may  be  caused  by  tickling  the 
nose  with  a  feather  or  by  the  use  of  snuff.  The  i)atient  should 
be  instructed  to  keep  the  mouth  closed  during  the  act  of 
sneezing. 

Bleeding  from  the  Nose. — This  may  follow  a  blow  upon 
the  nose  or  may  occur  sponstaneously.  Usually  the  hemor- 
rhage stops  after  a  few  minutes,  but  in  some  cases  the  bleeding 
may  be  se\'ere  enough  to  cause  alarming  symptoms. 

Treatment. — The  head  should  be  held  backward  so  that 
the  nose  is  elevated.  A  little  blood  swallowed  will  do  no 
harm.  The  collar  should  be  loosened  and  a  cold  cloth  or 
piece  of  ice  applied  to  the  back  of  the  neck.  This  will  relieve 
most  cases.  Other  methods  which  may  be  tried  are  the  placing 
of  a  piece  of  folded  card-board  beneath  the  iii)per  lij);  the 


MOUTH  201 

holding  of  the  soft  part  of  the  nose  firmly  together;  cloths 
dipped  in  ice-water  and  appHed  to  the  face;  and  ice-water 
sniffed  up  the  nose.  When  the  clot  forms,  allow  it  to  remain  in 
place.  Never  allow  the  patient  to  blow  the  nose.  This  only 
dislodges  the  clots  and  starts  the  bleeding  anew. 

In  obstinate  cases  a  plug  of  cotton  can  be  placed  in  the 
bleeding  nostril  to  check  the  hemorrhage.  A  long  strip  of 
loose  cotton  should  be  used,  not  bigger  than  the  finger,  and 
packed  back  into  the  bleeding  nostril  with  a  blunt  instru- 
ment, such  as  a  dull  lead-pencil. 

An  additional  measure,  which  has  never  failed  me  even  in 
severe  cases,  is  the  introduction  of  a  plug  of  snow  into  the 
bleeding  nostril.  When  snow  cannot  be  secured,  a  piece  of 
ice  is  pounded  in  the  corner  of  a  towel  until  it  is  of  the  con- 
sistency of  coarse  snow  and  then  molded  with  the  fingers 
roughly  into  the  shape  of  a  narrow  cone  and  pressed  into  the 
nostril. 

If  the  patient  becomes  faint  he  should  lie  down  with  the 
head  turned  to  one  side.  If  these  simple  measures  do  not 
stop  the  hemorrhage  within  a  few  minutes  a  physician  should 
be  called. 

MOUTH. 

Wounds  of  the  Mouth. — The  blood  supply  of  the  mouth 
and  lips  is  very  free,  consequently  there  is  apt  to  be  profuse 
hemorrhage  even  from  slight  wounds.  In  wounds  of  the 
mouth  or  tongue  it  is  impossible  to  apply  a  dressing.  If 
large  they  should  be  referred  to  a  physician  for  suture;  if 
small  the  patient  is  given  a  mouth  wash  (peroxide  of  hydrogen) 
to  use  frequently  and  the  wounds  are  let  alone. 

Hemorrhage  from  the  Mouth. — Bleeding  from  the  mouth 
may  come  from  a  wound  of  the  mouth  or  throat,  or  it  may 
be  coughed  or  vomited  up.  Always  examine  the  mouth 
carefully  to  see  whether  the  blood  which  is  spit  up  comes 
from  a  local  injury  or  from  some  of  the  internal  cavities, 
such  as  the  lungs  or  stomach. 

Treatment. — When  the  blood  comes  from  a  cut  on  the 
tongue  or  lip  it  may  be  stopped  by  direct  pressm-e-  with  a 
compress  held  in  place  with  your  finger.    When  there  is  per- 


202  REGIOXAL   l.WJURIES 

sisttMit  blocdiuu;  after  the  extraction  of  a  tooth  the  cavity 
may  he  j^aeked  with  a  small  pluu;  of  cotton.  In  most  cases 
the  hleecling  stops  spontaneously,  hnt  if  it  i)ersists  the  patient 
may  he  given  ice  to  snck  and  a  mouth  wash  of  ])eroxide  of 
hydrogen  (one-half  strength). 

Hemorrhage  from  the  Lungs. — This  condition  is  known  as 
hemoptysis,  and  is  connnonly  caused  by  pulmonary  tuber- 
culosis. The  blood  is  bright  red  and  frothy  and  is  coughed 
up.  The  condition  is  rarely  followed  by  fatal  consequences, 
but  the  patient  is  usually  greatly  alarmed.  If  the  bleeding 
has  been  profuse  or  prolonged  the  i)atient  is  ])alc  and  restless, 
and  there  are  the  other  symptoms  of  internal  hemorrhage. 

Treatment. — l\it  the  patient  to  bed  with  the  head  low  and 
try  to  keep  him  as  quiet  as  possible.  Give  him  a  cup  in 
which  to  exi)ectorate,  so  that  he  may  spit  out  the  blood 
without  raising  his  head.  An  ice-cap  is  placed  over  the 
chest  and  the  patient  is  given  ice  to  suck.  ^Medical  atten- 
tion should  be  secured  as  soon  as  possible.  The  diet  should 
be  limited  to  fluids,  always  given  cold. 

Hemorrhage  from  the  Stomach. — Hemorrhage  from  the 
stomach,  or  hematemesis,  is  caused  by  the  rupture  of  a  vein 
in  the  stomach,  or  as  the  result  of  bleeding  from  an  ulcer. 
The  blood  is  vomited  instead  of  being  coughed  uj),  as  in 
hemoi)tysis,  and  is  darker  in  color.  In  some  cases  it  may  be 
changed  to  a  very  dark  brown,  having  the  appearance  of 
coffee  grounds.  It  may  be  mixed  with  partially  digested 
food.  The  general  symptoms  are  those  of  internal  hemor- 
rhage. 

Treatment. — The  patient  should  be  i)laced  in  bed  with  an 
ice-cap  placed  over  the  stomach.  Al)solutely  nothing  is 
given  by  mouth,  not  even  cold  water,  but  the  patient  may 
be  given  ice  to  suck  if  the  fluid  is  not  swallowed.  Otherwise 
the  treatment  is  the  same  as  for  internal  hemorrhage. 

Internal  Hemorrhage. — The  symptoms  of  internal  hemor- 
rhage are  exactly  the  same  as  those  of  external  hemorrhage, 
except  that  the  blood  is  not  seen  or  only  part  of  it  may  appear 
at  the  surface. 

In  hemoptysis  and  hematemesis,  or  after  a  stab  wound  of 
the  abdomen  or  chest,  the  diagnosis  is  comparatively  easy; 


MOUTH  203 

but  after  injuries  to  the  abdomen,  in  which  there  is  no  vom- 
iting of  blood,  the  diagnosis  is  much  more  difficult. 

There  is  always  paleness  associated  with  a  rapid  pulse 
and  shortness  of  breath  (air-hunger).  The  hands  and  feet 
are  cold,  and  the  patient  is  restless  and  complains  of  intense 
thirst. 

Treatment. — The  patient  is  placed  flat  in  bed  and  kept 
absolutely  quiet,  not  even  being  allowed  to  get  up  to  go  to 
the  toilet.  If  the  location  of  the  bleeding  is  known,  an  ice- 
cap or  a  cold  compress  is  placed  over  this  point.  The  patient 
is  covered  well  with  blankets  and  hot- water  bags  are  placed 
against  the  legs  and  feet. 

If  the  hemorrhage  comes  from  the  stomach,  nothing  should 
be  given  by  mouth;  otherwise  cold  drinks  may  be  given. 
Stimulants  are  never  given  unless  the  condition  becomes 
serious,  in  which  case  coffee  or  aromatic  spirits  of  ammonia 
may  be  given  by  mouth,  or  coffee  solution  may  be  injected 
into  the  rectum. 

The  patient  should  be  kept  absolutely  quiet  until  the 
physician  arrives.  This  is  one  of  the  cases  where  it  is  dan- 
gerous to  attempt  to  transport  the  patient  even  if  a  physi- 
cian is  not  obtainable  for  several  days.  Patients  receiving 
such  injuries  on  the  battlefield  are  not  able  to  stand 
transportation  to  the  base  hospitals. 

Foreign  Bodies  in  the  Throat. — A  pin,  a  coin,  or  other 
small  object  may  be  accidentally  swallowed.  When  it  is 
drawn  into  the  air  passages  it  causes  choking,  which  has 
been  described  elsewhere.  If  it  passes  down  into  the  throat 
it  may  remain  lodged  there,  or  it  may  pass  down  into  the 
stomach. 

If  it  remains  in  the  upper  part  of  the  throat  it  can  some- 
times be  seen  and  removed.  ]\Iore  often  it  is  out  of  sight, 
but  the  patient  feels  it  as  a  hard  lump  in  the  lower  part  of 
the  neck. 

Often  if  the  throat  is  tickled  the  patient  will  vomit,  the 
force  of  the  vomiting  removing  the  foreign  body.  If  this 
does  not  occur  the  patient  may  swallow"  the  object  by  tak- 
ing a  large  drink  of  water  or  a  mouthful  of  food.  ^Mien  the 
object  is  sharp,  such  as  a  pin,  there  is  daiiger  that  the  sharp 


204  RECIOXAL   IXJFRIES 

])oint  may  injure  the  stoinach  or  the  intestines.  Conse- 
quently it  is  advisable  to  {;ive  at  once  a  large  amount  of 
some  food,  which  is  digested  with  difficult^',  the  theory  being 
that  the  sharp  object  will  pass  through  the  intestines  firmly 
embedded  in  the  mass.  Uncooked  rolled  oats  or  bran  are 
excellent  substances  for  this  ])urpose. 

CHEST. 

Contusion  of  the  Chest. — Hard  blows  upon  the  chest  or 
sudden  pressure  upon  the  chest,  such  as  is  seen  in  "  buffer 
accidents,"  result  in  a  momentary  cessation  of  respiration. 
The  patient  is  unable  to  "catch"  his  breath  and  the  face 
and  neck  become  blue  and  congested. 

Such  cases  usually  recover  after  a  short  rest.  If  there  is 
difficulty  in  breathing,  artificial  respiration  should  be  begun. 
After  the  first  effects  of  the  injury  have  passed  away,  examine 
carefully  for  fracture  of  the  ribs. 

Wounds  of  the  Chest. — These  are  important  because  they 
may  penetrate  the  chest  cavity  and  injure  the  heart  or  lungs. 

If  the  heart  has  been  injured  the  pulse  is  rapid  and  weak 
and  the  patient  shows  a  marked  degree  of  shock.  He  should 
be  kept  strictly  at  rest  until  the  arri^■al  of  the  physician,  and 
the  treatment  given  as  outlined  under  Internal  Hemorrhage. 
The  surface  of  tlie  wounds  should  be  painted  with  tincture 
of  iodin  and  a  dry  dressing  applied. 

^Yhen  the  chest  cavity  is  entered  the  air  rushes  in  through 
the  opening  during  inspiration  and  is  expelled  during  ex])i- 
ration.  If  the  wound  is  carefully  examined  the  entrance  and 
exit  of  air  can  often  be  detected.  In  addition,  if  the  lung  is 
injured,  the  patient  complains  of  cough  and  brings  up 
blood-stained  expectoration.  If  the  air  escapes  beneath  the 
skin  a  condition  known  as  subcutaneous  emphysema  results, 
in  which  there  is  swelling  in  tlie  region  of  the  wound.  This 
swelling  is  due  to  air  in  the  tissues,  and  when  i)ressed  upon 
gives  a  characteristic  sensation  of  crepitus. 

Treatment. — The  woimd  should  be  dressed  with  a  small 
sterile  dressing,  after  preliminary  })ainting  with  iodin,  and 
the  entire  dressing  covered  with  adhesive  i)laster  or  other 


ABDOMEN 


205 


material  which  \\'ill  not  [)ermit  the  passa<re  of  air.  In  most 
cases  til  is  gradually  relieves  the  l)reathiiig;  in  a  few  cases 
the  breathi]ig  is  made  worse.  If  the  latter  is  the  case  the 
dressing  should,  of  course,  be  removed.  Otherwise  the  treat- 
ment is  the  same  as  for  internal  hemorrhage. 

ABDOMEN. 

Contusion  of  the  Abdomen. — Contusion  of  the  abdomen 
results  in  a  momentary  shortness  of  breath  which  soon 
passes  away.  In  addition,  contusion  of  the  abdomen  may 
result  in  an  injury  to  one  of  the  abdominal  organs  which 
may  have  serious  consequences.  The  soft  organs,  such  as 
the  liver  and  the  kidneys,  may  be  torn  and  lacerated,  in 


Fig.  131. — Rupture  of  the  right  kidney  following  blow  on  the  back. 
(Ashhurst.) 


which  case  internal  hemorrhage  is  apt  to  be  profuse;  or  one 
of  the  hollow  organs,  such  as  the  stomach,  intestines,  or 
bladder,  may  be  ruptured,  with  the  escape  of  their  contents 
into  the  abdominal  cavity,  in  which  case  hemorrhage  is  less 
marked,  but  the  escape  of  the  fluid  contents  of  the  ruptiu-ed 
organ  is  apt  to  cause  peritonitis  and  death. 


IHHI  h'l-:(;i().\AL    I.WU'h'IES 

Symptoms. — The  symptoms  vary  with  the  sovrrity  of  the 
injur}  'I'Ikmv  is  ahvays  more  or  loss  siiock,  which  may 
luerije  imi)ercri)tibly  into  internal  hemorrliauc;  oi-  the  syni])- 
toms  of  shock  may  jiass  away  entirely,  the  symptoms  of 
hemorrhaije   not   bocomint;-   cNidciit    for   an    hour   or  more. 

When  a  hollow  ()ru;an  is  ruptured  there  isa])t  to  be  marked 
and  prolonged  shock,  with  severe  internal  i)ain;  but  these 
symptoms  may  gradually  grow  less,  so  that  after  a  few  hours 
the  patient  feels  much  im]:)roved,  apj^arently  on  the  road  to 
recovery.  The  ])ain  and  tenderness  never  entirely  disappear, 
however,  becoming  at  a  later  ])eriod  more  marked,  and 
gradually  develoi)ing  into  the  well-defined  i)ain  and  tender- 
ness of  peritonitis. 

The  vomiting  of  blood,  or  the  ])assing  of  blood  in  the  urine, 
or  in  the  stools,  all  indicate  injury  to  the  abdominal  organs. 
The  inability  to  urinate  may  mean  a  ruptured  bladder. 
Occurring  several  hours  after  the  injury,  fe^'er  and  \'omiting 
indicate  peritonitis. 

Treatment. — 1.  Treat  the  jjrimarv-  shock.  This  treatment 
has  been  outlined  under  shock.  It  is  generally  safer  not  to 
give  fluids  by  the  mouth  until  it  is  certain  that  tlic  stomach 
is  not  ruptured. 

2.  If  internal  hemorrhage  occurs,  ai)])ly  an  ice-caj)  and 
give  the  other  treatment  recpiired  for  this  condition.  It 
will  be  noted  that  the  treatment  of  shock  and  that  of  internal 
hemorrhage  are  practically  identical. 

3.  In  order  to  avoid  peritonitis,  the  patient  should  be 
given  nothing  by  mouth  until  it  is  reasonably  certain  that 
there  is  no  serious  injury  to  the  abdominal  organs.  If  thirst 
is  extreme,  six  to  eight  ounces  of  coffee  solution  or  ordinary 
water  may  be  injected  into  the  rectum  and  retained.  The 
absorption  of  this  solution  will  relieve  the  thirst.  An  ice-cap 
over  the  area  of  tenderness  serves  to  limit  the  hemorrhage, 
to  relieve  the  pain,  and  to  ])revent  ])eritonitis. 

It  sometimes  happens  that  after  an  injury  a  patient,  after 
a  negative  examination  by  a  physician,  a  day  or  two  later 
develops  severe  pain  in  the  abdomen,  associated  with  nausea 
or  vomiting.  Such  a  case  is  probably  one  in  which  there  is 
secondary  peritonitis  brought  on  by  the  taking  of  food. 


ABDOMEN  207 

Always  keep  patients,  especially  chiklren,  who  have 
received  a  severe  abdominal  injury  in  bed  for  a  day  or  hm^er 
after  the  injury,  even  if  they  claim  to  feel  perfectly  well. 
If  there  is  no  pain  and  only  slight  tenderness,  water,  tea, 
broth,  or  other  fluids  containing  no  solid  material  may  })e 
taken  in  small  quantities.  Milk  and  fluids  containing  milk 
should  not  be  allowed.^ 

Wounds  of  the  Abdomen. — Punctured  wounds  of  the 
abdomen  should  be  dressed  as  any  other  wounds.  They 
should  never  be  probed.  The  possibility  of  internal  hemor- 
rhage and  puncture  of  a  hollow  organ  should  be  borne  in 
mind  and  the  treatment  carried  out  as  outlined  above. 
Every  patient  with  a  deep  punctured  wound  of  the  abdomen 
should  be  kept  in  bed  for  at  least  a  w^eek. 

If  there  is  a  large  wound,  allowing  the  escape  of  the  intes- 
tines, a  towel  moistened  with  warm  salt  solution  (one  tea- 
spoonful  of  salt  to  a  pint  of  water)  should  be  placed  over 
the  intestines  and  kept  moist  until  the  arrival  of  a  physician. 
If  the  intestines  become  dry  they  lose  their  vitality  and 
may  become  gangrenous. 

Bullet  wounds  of  the  abdomen  are  treated  exactly  the 
same  as  punctured  wounds.     Never  probe  for  the  bullet. 

Strangulated  Hernia. — A  hernia,  or  rupture,  is  a  protru- 
sion of  a  small  loop  of  the  intestine  through  an  opening  in 
the  abdominal  wall.  In  the  groins  there  are  four  natural 
openings  which  may  be  slightly  stretched,  allowing  a  loop 
of  intestine  to  slip  through.  This  is  a  rupture,  and  can  be 
felt  as  a  soft  lump  beneath  the  skin.  Persons  who  have  a 
rupture  are  usually  aware  of  the  fact,  and  wear  a  truss  which 
is  fitted  with  a  pad  so  adjusted  as  to  close  the  hernial  opening 
and  prevent  the  protrusion  of  the  bowel. 

It  occasionally  happens  that  the  small  loop  of  bowel  gets 
crowded  through  the  opening  and  squeezed  off  so  that  it 
cannot  be  pushed  back.    It  is  then  said  to  be  strangulated. 

Symptoms. — ^The  symptoms  are  severe  pain,  marked  pros- 
tration, nausea,  and  vomiting.    As  the  bowel  is  pinched  off 

^  It  must  be  remembered  that  milk,  when  taken  into  the  stomach  forms 
curds,  so  that,  as  a  rule,  milk  is  not  suitable  for  patients  who  are  forbidden 
solid  food. 


20S  REGIONAL   IXJIUIES 

there  is  absolute  constijiation,  \\liicli,  unless  velie\'e(l,  ends, 
in  death. 

Treatment,  'i'he  patient  should  he  ])laced  Hat  on  his  haek 
w  ith  the  foot  of  the  hed  elevated.  The  thighs  are  drawn  up 
in  a  relaxed  i)osition  and  an  ice-cap  is  placed  over  the  rup- 
ture. The  i)atient  usually  knows  how  to  reduce  the  rup- 
ture himself.  If  he  is  unable  to  reduce  it  a  physician  should 
be  sent  for  at  once,  because  after  a  fe^^'  hoin-s,  the  bowel,  if 
completely  strangulated  (that  is  if  the  constriction  about  the 
neck  is  tight  enough  to  shut  off  all  the  circulation),  may 
become  gangrenous  and  death  residt. 

RECTUM,  BLADDER  AND  REPRODUCTIVE  ORGANS. 

Rupture  of  the  bladder  has  already  been  mentioned  under 
( 'ontusion  of  the  Abdomen.  Hemorrhage  of  the  bladder  or 
of  the  organs  of  reimxluction  should  be  treated  by  absolute 
rest  in  bed  combined  with  cold  compresses  over  the  injured 
parts.  Contusions  of  the  reproductive  organs  are  apt  to 
be  followed  by  shock  out  of  all  proportion  to  the  apparent 
injury. 

Hemorrhage  of  the  rectum,  commonly  the  result  of  i)iles, 
is  so  common  that  it  is  often  disregarded.  If  the  symptoms 
are  alarming  the  patient  should  be  put  to  bed  and  given  an 
enema  of  about  eight  ounces  of  cold  water. 

INJURIES    TO    THE   EXTREMITIES. 

Crushing  Injuries. — The  so-called  mangle  injuries  of  the 
extremities  are  Very  common.  They  are  usually  caused  by 
catching  the  hands  or  feet  in  the  cogs  of  machinery,  the 
result  being  multiple  lacerations  and  fractures.  There  is 
considerable  shock,  but  often  comparatively  little  hemor- 
rhage. It  is  usually  difficult  to  apply  iodin  to  the  entire 
area,  so  I  have  made  it  a  practice  to  treat  the  cases  by  apply- 
ing large  pieces  of  gauze  soaked  in  weak  alcohol  (25  to  50 
per  cent.)  and  loosely  bandaging  the  whole  in  place.  If 
there  is  consideraljle  hemorrhage  a  large  piece  of  cotton  may 
be  wrapped  around  the  first  dressing  and  a  tight  bandage 


INJURIES   TO   THE  EXTREMITIES 


209 


applied.    The  cotton  fits  into  the  crevices  and  usually  stops 
the  hemorrhage.    A  tourniquet  is  very  rarely  required. 

Gunshot  and  shrapnel  wounds  are  very  similar  to  these 
crushing  injuries.     The  large  open  wounds  (Fig.  132)  should 


Fig.  132. — Shrapnel  wound  of 
the  leg  necessitating  amputation. 
(Park.) 


Fig.  1.33.— Bullet  wound  of  the 
calf  shomng  points  of  entrance 
and  exit.  Five  days  after  injury. 
(Ashhurst.) 


be  treated  as  outlined  above.     Simple  bullet  wounds  (Fig. 
133)  should  be   painted  with   tincture  of   iodin;   they  are 
never  probed. 
14 


210 


REGIONAL  INJURIES 


Division  of  the  Tendons.  In  wounds  alK)iit  the  wrist  and 
ankle  the  tendons  are  very  apt  to  be  cut.  Unless  the  cut 
entls  are  sewed  together  the  use  of  the  tendon  will  be  perma- 
nently lost.  Such  an  injury  may  result  from  what  is  appar- 
ently a  very  slight  wound.  A  wound  about  the  wrist,  for 
example,  may  result  in  the  loss  of  the  ability  to  bend  one  or 
more  fingers;  or  the  fingers  may  remain  bent,  the  power  to 
straighten  them  again  being  lost.  There  is  no  pain  or  swell- 
ing of  the  finger  and  the  joints  may  freely  be  moved  by 
the  examiner. 

Treatment. — The  wound  should  be  treated  according  to 
general  principles  and  a  surgeon  secured  to  suture  the  cut 
ends  of  the  tendons  as  soon  as  possible.     However,  there  is 


Fig.    1.34. — Rupture   of   the    tendon    of    the    little    finf^er.     The    iKiticnt    is 
unable  to  straighten  the  finger.     (Ashhunst.) 


not  as  great  urgency  about  this  as  about  many  other  emer- 
gencies. While  it  is  desirable  to  have  the  operation  performed 
the  same  day,  a  perfectly  satisfactory  result  may  be  obtained 
any  time  within  the  first  few  days. 

Occasionally  a  wound  is  seen  which  heals  entirely  before 
the  loss  of  motion  is  detected.  In  such  cases  incision  and 
suture  of  the  tendon  should  be  performed  by  a  competent 
surgeon. 

Division  of  Nerves. — When  a  sensory  nerve  is  cut  there  is 
numbness  and  loss  of  sensation  in  the  region  supplied  by  the 
nerve.  When  a  motor  nerve  is  cut  the  muscles  which  it 
supplies  are  completely  paralyzed.  Division  of  a  mixed 
nerve  causes  both  sensory  and  motor  paralysis. 


INJURlEti   TO   THE  EXTREMITIE>S  211 

Treatment. — The  wound  is  treated  on  general  princii)les, 
and  if  a  motor  nerve  is  eut  a  surgeon  is  secured  to  suture 
the  ends.  If  a  sensory  nerve  is  cut  no  attempt  is  made  to 
suture  it.  The  sensation  returns  after  about  three  months, 
the  adjacent  nerves  growing  inward  to  supply  the  anesthetic 
area. 

'  Foreign  Body. — Occasionally  a  foreign  body,  such  as  a 
splinter  or  a  sliver  of  steel,  is  introduced  beneath  the  skin. 
If  it  can  be  seen,  grasp  it  with  a  pair  of  fine  forceps  and 
withdraw  it.  If  it  is  deeper,  slightly  enlarge  the  wound  with 
a  sharp  knife  and  look  for  the  end  of  the  splinter.  If  it  can 
now  be  easily  seen,  withdraw  it.  If  it  cannot  be  easily  seen, 
dress  the  wound  but  never  probe  deeply  into  the  tissues.  If 
the  splinter  is  large  it  is  almost  sure  to  cause  suppuration, 
consequently  it  should  be  removed  by  a  surgeon  as  soon  as 
possible. 

A  piece  of  needle  is  sometimes  driven  into  the  hand.  If 
it  is  entirely  out  of  sight  it  is  useless  to  incise  to  try  to  find 
it.  Either  allow  it  to  remain  or  apply  for  surgical  aid. 
Needles  and  other  pieces  of  metal  are  located  by  the  .r-rays. 
Hypodermic  needles  often  break  oft'  where  the  blade  of  the 
needle  joins  the  screw  cap.  Consequently,  those  who  have 
to  give  hypodermic  injections  should  be  careful  not  to  insert 
the  needle  its  entire  length. 

A  fish-hook  may  catch  in  the  hands  or  other  parts  of  the 
body.  If  the  barb  is  beneath  the  skin  the  point  should  be 
pushed  forward  so  as  to  come  out  at  another  point.  The 
barbed  end  is  now  cut  away  with  a  pair  of  wire-cutters  and 
the  hook  drawn  back.     It  is  now  easily  drawn  out  of  the  skin. 

Bullet  wounds  of  the  arms  and  legs  should  be  sterilized 
with  tincture  of  iodin  and  a  dry  dressing  applied.  Never 
probe  for  the  bullet.  The  bullet  may  divide  a  tendon  or 
nerve  in  the  same  manner  as  occurs  in  an  incised  womid. 

Muscle  Strain. — ^In  lifting  a  heavy  weight  or  in  sudden 
twisting  mo\Tments  the  muscles  may  be  slightly  over- 
stretched and  torn.  This  is  known  as  muscle  strain.  It  is 
painful  but  otherwise  has  no  significance. 

Treatment. — Massage  with  a  strong  liniment,  such  as 
chloroform  liniment,  and  the  application  of  heat  is  usually 


•212 


REGIONAL  IXJUIilES 


all  that  is  required.  A  firm  baiulajiie  may  be  worn  for  a 
few  days  if  the  ]>ain  is  severe  and  if  support  is  desired. 

Rupture  of  a  Muscle. — Tn  some  eases  a  nuiscle  or  tendon 
is  torn  entirely  aert>ss.  This  hapjxMis  most  fretjuently  in  the 
biceps  of  the  arm,  the  tendo-Aehillis  behind  the  heel,  and  the 
tendon  attached  to  the  knee-caj).  There  is  severe  pain  and 
loss  of  strength  in  the  aii'ected  jjart.  As  the  symptoms 
resemble  fracture  it  is  advisable  to  appl>'  a  splint  and  ,keep 
the  part  at  rest  until  the  ser\ices  of  a  ])hysician  can  be 
secured. 

Blisters  and  Abrasions  of  the  Feet.—  These  injuries  are 
usually  the  result  of  irritation  and  rubbing  caused  by  poorly 
fitted  shoes. 


Fig.  135. — Pmiicr  siik-s  for  normal 
feet.      ( Wliilnian.) 


Fig.  136. — Shopinaker's   feet. 

(Whitman.) 


Sore  feet  may  be  prevented  by  the  use  of  properly  fitted 
shoes  and  clean,  dry  socks.  The  U.  S.  Army  shoe,  built  on 
the  Munson  last,  is  a  very  satisfactory  one.  The  ordinary 
shoes  which  cramp  the  feet  are  unsuited  to  the  use  of  persons 
who  expect  to  walk  or  stand  on  their  feet  a  great  deal.  Sol- 
diers on  the  march  are  required  to  remove  the  shoes  after 
a  long  tramp  and  wash  the  feet,  carefully  drying  them  and 


INJURIES   TO   THE  EXTREMITIES  21. 3 

changing  their  socks.  Toe-nails  should  be  cut  squarely 
across  but  not  too  short. 

Treatment. — Vaselin  well  smeared  over  the  feet  and 
between  the  toes  will  prevent  soreness,  or  if  vaselin  cannot 
be  obtained,  talcum  powder  may  be  dusted  over  the  feet 
and  into  the  sock. 

Blisters  should  not  be  opened  but  carefully  covered  with 
adhesive  plaster.  Abrasions  should  be  well  washed,  dried, 
and  painted  with  tincture  of  iodin.  A  small  sterile  dressing 
no  larger  than  the  abrasion  is  then  applied  and  the  entire 
dressing  covered  with  narrow  strips  of  adhesive  plaster  so 
that  the  dressing  cannot  slip. 

Ingrowing  Toe-nails. — The  nail  should  be  cut  straight 
across,  never  at  the  side.  When  there  is  inflammation  the 
skin  is  separated  from  the  edge  of  the  nail  by  packing  in  a 
small  strip  of  cotton  dipped  in  alcohol,  after  having  painted 
the  entire  area  with  tincture  of  iodin.  A  wet  boric  dressing 
applied  at  night  will  often  relieve  the  pain  and  allay  the 
inflammation.  Carbolated  vaselin  may  be  applied  in  trouble- 
some cases. 

Splinter  Beneath  the  Nail. — A  splinter  is  sometimes  run 
beneath  the  nail.  It  should  be  withdrawn  with  a  pair  of 
forceps  and  a  tooth-pick  dipped  in  tincture  of  iodin  passed 
along  the  path  of  puncture.  This  will  usually  prevent 
inflammation.  If  it  is  difficult  to  secure  the  splinter  a  V- 
shaped  piece  may  be  cut  from  the  nail. 

Blood  Blisters. — These  are  really  small  contusions.  The 
blister  should  be  protected  with  a  small  dressing.  It  is  never 
opened  unless  infected.  Infection  is  shown  by  increased 
pain  and  redness  about  the  blister.  If  this  occurs,  snip  the 
thin  top  of  the  blister  away  and  treat  as  an  open  wound. 


CHAPTER  X. 

POISONING. 

Generally  speaking,  anything  A\-hic-li,  when  introduced 
into  the  body,  causes  sickness  or  death  is  a  poison;  but  in 
the  following  pages  the  only  poisons  taken  into  considera- 
tion will  be  those  which,  swallowed  either  by  accident  or 
intent,  cause  acute  symptoms. 

Poisons  are  taken  either  accidentally,  or  purposely  with 
suicidal  intent.  The  particular  poisons  taken  for  suicidal 
purposes  vary  from  year  to  year.  Several  years  ago  carbolic 
acid  was  largely  used  for  this  purpose,  but  recently  bichloride 
of  mercury  poisoning  is  a  frequent  cause  of  death.  This  is  be- 
cause would-be  suicides  are  apt  to  follow  the  method  which 
first  occurs  to  them.  The  frequent  references  to  bichloride 
of  mercury  poisoning  in  the  daily  papers  made  the  name 
familiar  to  the  general  public,  so  that  when  the  desire  to 
end  life  comes  to  the  individual,  bichloride  of  mercury  is 
the  first  name  that  occurs  to  his  mind.  ^Yithout  doubt  in  a 
short  time  there  will  be  a  particularly  spectacular  case  in 
which  some  other  form  of  poison  is  used  anfl  the  resulting 
publicity  will  serve  to  "popularize"  some  other  drug. 

Poisons  may  be  divided  into  three  classes  according  to 
their  action  upon  the  human  body: 

1.  Those  which  act  chiefly  upon  the  stomach  and  gastro- 
intestinal canal.  These  cause  violent  pain  and  irritation, 
first  in  the  stomach  and  later  in  the  intestines.  Such  ])oisons 
include  caustic  acids,  caustic  alkalies,  nitrate  of  silver,  croton 
oil,  and  sugar  of  lead. 

2.  Those  which  cause  little  or  no  local  irritation  but 
produce  serious  general  symptoms,  such  as  ojjiiun,  chloral, 
belladonna,  or  strychnin. 

3.  Those  having  both  local  and  general  eft'ects.  These 
include  bichloride  of  mercury,  cantharides,  carbolic  acid, 
phosi)horus,  aconite,  and  animal  ptomains. 


POISONING  215 

Symptoms. — The  symptoms  vary  according  to  the  partic- 
ular poison  which  has  been  taken.  Irritant  poisons  are  ai)t 
to  cause  severe  abdominal  pain,  with  vomiting  and  cramps. 
There  may  be  burns  or  signs  of  irritation  about  the  mouth 
and  throat. 

The  strictly  general  poisons  show  no  irritation  about  the 
mouth,  nor  is  there  accompanying  abdominal  pain.  They 
act  specially  upon  the  nervous  system,  frequently  causing 
unconsciousness  or  convulsions. 

If  a  patient  previously  in  good  health  is  suddenly  taken 
sick  after  taking  medicine,  poisoning  should  be  at  once 
suspected.  In  all  cases  look  for  the  bottle!  Suicides  will 
rarely  lie  if  asked  point-blank  if  they  have  taken  anything 
which  might  be  poisonous.  They  frequently  have  had  a 
change  of  heart  and  are  very  willing  to  give  all  desired  infor- 
mation. In  other  cases  the  fact  that  they  are  giving  evasive 
answers  may  be  easily  detected. 

Treatment. — If  an  undetermined  poison  has  been  taken 
into  the  stomach  the  treatment  is  as  follows: 

1.  Dilute  the  poison. 

2.  Empty  the  stomach. 

3.  Give  an  antidote. 

4.  Empty  the  bowels. 

5.  Support  the  body  strength. 

To  Dilute  the  Poison. — The  poison  may  be  diluted  with 
water  or  other  fluid.  The  patient  should  be  required  at 
once  to  drink  at  least  two  glasses  of  the  nearest  harmless 
fluid  at  hand.  Tepid,  bland  fluids  are  especially  desirable 
for  reasons  which  will  be  discussed  later,  but  any  fluid,  such 
as  water,  coffee,  soup,  lemonade,  beer  or  any  other  compara- 
tively harmless  fluid  may  be  given.  This  serves  to  dilute 
the  poison  so  that  the  local  irritation  is  less,  and  at  the 
same  time  to  delay  its  absorption,  so  that  the  general  symp- 
toms are  slower  in  making  their  appearance. 

To  Empty  the  Stomach. — After  the  poison  is  well  diluted  the 
stomach  should  be  emptied.  This  is  best  done  by  tickling  the 
back  of  the  throat  with  the  tip  of  the  finger.  It  is  sometimes 
sufficient  simply  to  stick  the  finger  down  the  tliroat,  but  this 
often  fails,  in  which  case  the  patient  should  be  instructed  to 


210   ,  POISONING 

pass  the  finger  back  over  the  tongue  until  the  tip  barely 
touches  the  back  of  the  throat  and  then  to  move  the  tip 
ra])i(lly  up  and  d()\vn.  This  almost  invariably  results  in 
vomiting.  The  i)rocess  may  have  to  be  repeated  several 
times  before  the  stomach  empties  itself  satisfactorily. 

The  less  time  that  is  allowed  to  elapse  between  the  time 
the  dose  is  taken  and  the  vomiting  of  the  diluted  poison  the 
better  are  the  chances  for  the  i)a.tient.  After  the  stomach 
is  apparently  satisfactorily  emptied  the  patient  is  required 
to  take  two  glasses  of  tepid  water  or  other  fluid  and  again 
to  vomit.  This  process  is  repeated  several  times  until  it  is 
certain  that  all  the  imabsorbed  poison  has  been  removed  from 
the  stomach. 

Emetics  are  advised  in  poisoning  and  may  be  used  if  avail- 
able. They  are  substances  which  when  taken  into  the  stom- 
ach cause  vomiting.  They  take  time  to  prepare  and  are  infin- 
itely inferior  to  the  method  just  described.  The  chief 
emetics  in  common  use  are  salt,  mustard,  and  ipecac.  A 
tablespoonful  of  mustard  or  a  teaspoonful  of  salt  or  syrup  of 
ipecac  mixed  in  a  glassful  of  tepid  water  will  usually  result 
in  vomiting.  They  should  be  given  to  patients  who  are 
imable  to  bring  on  vomiting  by  the  method  just  described. 
The  same  solutions  may  be  given  to  patients  who  vomit  easily, 
the  nauseating  character  of  the  fluids  making  the  induction 
of  vomiting  by  the  finger  much  easier.  Never  wait  to  secure 
an  emetic,  however,  but  give  the  first  fluid  that  is  at  hand. 
One  physician  always  gave  dishwater  as  an  emetic,  saying 
that  the  mere  drinking  of  the  dishwater  was  sufficient  to 
make  most  persons  vomit.  Sea  water,  especially  if  tepid,  is 
an  excellent  emetic.  If  used  skilfully  the  stomach-tube  may 
be  employed  to  wash  out  the  stomach. 

The  Stoinach-tiihc. — The  stomach-tube  is  a  mediinn  soft- 
rubber  tube  about  three  feet  long  and  about  the  size  of  the 
little  finger.  It  is  used  to  remove  poisons  and  to  wash  out 
the  stomach,  or  occasionally  to  introduce  liquid  food  into 
the  stomach. 

It  is  wiser  not  to  attempt  to  pass  a  stomach  tube  unless 
you  ha\'e  had  a  practical  demonstration.  The  method  is  as 
follows:  The  patient  is  seated  in  a  chair  and  the  end  of  the 


POISONING  217 

stomach-tube,  previously  dipped  in  glycerin  or  olive  oil,  is 
passed  to  the  back  part  of  the  tongue.    The  patient  is  now 


Fig.  137. — Stomach-tube  and  aspirator.     (Aaron.) 

told  to  close  the  lips  and  swallow,  gentle  pressure  being  made 
at  the  same  time  on  the  tube.  If  there  is  a  choking  sensa- 
tion, or  if  the  patient  is  unable  to  breathe,  the  tube  should 


218 


POISONING 


be  removed,    l^siially  it  must  be  puslied  down  about  fifteen 
inches  to  rcacli  the  stomacli.     When  the  stomach  is  reached 


^^V  '  '^'^^^^^^^1^1 

^^^     "^  -^  '' 

i  M*^    1 

Fig.  138. — This  tube  is  used  without  a  bulb.     The  tube  is  passed  and  water 
poured  into  the  funnel  and  allowed  to  run  into  the  stomach.     (Hare.) 


a  funnel  can  be  inserted  in  the  other  end  of  the  tube  and  luke- 
warm water  poured  into  the  stomach.  After  about  two 
glassfuls  have  been  poured  down  the  tube  the  funnel  is  low- 


POISONING 


219 


ered'and  the  fluid  is  allowed  to  run  out.  Repeated  washings 
will  remove  all  the  poison  from  the  stomach,  but  in  unskilled 
hands  this  method  is  inferior  to  the  method  of  emptying 
the  stomach  previously  outlined.  As  it  is  not  without 
danger,  it  should  not  be  attempted  until  it  has  been  thor- 
oughly demonstrated  by  an  instructor. 


Fig.  139. — Just  as  the  last  portion  of  the  water  is  about  to  disappear 
down  the  tube  the  funnel  end  is  lowered  and  the  contents  of  the  stomach 
are  siphoned  out.     (Hare.) 

Antidotes  for  Poisons. — An  antidote  is  a  substance  which 
neutralizes  a  poison.  It  may  neutralize  it  chemically  as  acids 
neutralize  alkalies,  or  it  may  neutralize  it  by  rendering  it 
insoluble. 


220  poisnxfxa 

\Vhilo  antidotes  have  been  given  third  ])laee  in  the  treat- 
ment of  poisoning  it  is  hardly  neeessary  to  state  that  they 
should  be  given  at  once  if  possible.  Thus  milk  is  the  anti- 
dote for  bichloride  of  mercury  and  should  always  be  given  at 
once  if  at  hand;  but  if  no  milk  is  a\ailable  any  other  fluid 
may  be  given,  the  point  being  that  it  is  a  mistake  to  delay 
the  emptying  of  the  stomach  in  order  to  secure  an  antidote. 
Use  the  antidote  as  soon  as  it  is  at  hand,  but  dilute  the 
jioison  and  emj^ty  the  stomach  at  once  by  the  best  available 
means. 

Certain  substances  are  known  as  general  antidotes,  that 
is,  they  are  antidotes  for  many  poisons.  Alkalies,  such  as 
baking  soda  or  lime-water,  are  general  antidotes  for  all  acids 
(except  carbolic  acid),  and  acids,  such  as  vinegar  or  lemon 
juice,  are  antidotes  for  all  alkalies.  Milk  and  other  substances 
containing  albumen  (white  of  egg),  are  antidotes  for  all 
mineral  poisons,  including  nitrate  of  silver  and  })ichloride  of 
mercury,  as  well  as  for  all  acids  and  alkalies.^  Albuminous 
substances  combine  with  the  poison  and  render  it  less  harm- 
ful, })ut  do  not  neutralize  it,  so  that  the  stomach  must  be 
emptied  before  digestion  can  take  place.  Tea,  because  it 
contains  tannic  acid,  is  the  antidote  for  most  plant  poisons, 
such  as  opium,  belladonna,  and  aconite. 

[Milk  should  always  be  borne  in  mind  in  case  of  ])oisoning, 
because  it  can  nearly  always  be  obtained,  and  it  is  the 
antidote  for  many  poisons.    It  never  causes  harm. 

To  Empty  the  Bowels. — After  the  patient  has  vomited 
several  times  a  cathartic  should  be  given  to  evacuate,  or 
empty,  the  bowels.  No  matter  how  (piickly  the  stomach 
has  been  emptied  it  is  almost  certain  that  some  of  the  poison 
has  passed  out  of  the  stomach  into  the  intestine.  This  por- 
tion can  only  be  gotten  rid  of  by  the  use  of  a  cathartic,  and 
•it  is  a(h'isable  to  use  a  (juickly  acting  cathartic,  such  as 
castor  oil  or  salts,^  so  that  the  poisonous  material  may  be 
hurried  through  the  bowel.  Cascara,  rhubarb,  calomel,  and 
all  the  slower  acting  cathartics  are  not  suitable  for  this  pur- 

'  Milk  is  less  suitable  for  the  purpose  of  neutraliziup;  acids  or  alkalies 
than  the  chemifal  antidote  (baking  soda  or  vinegar) ,  but  it  is  an  additional 
protection  and  may  be  given  if  the  fheniieal  antidote  is  not  ol)tainable. 

2  Two  or  three  tablesi)oonfuls  of  castor  oil  or  two  rounded  tablespoonfuls 
of  Epsom  (If  Hoclicllc  .salts  lire  the  proper  doses  for  an  adult. 


POISONING  221 

pose.  If  the  cathartic  is  vomited  the  dose  should  ha  repeated 
after  a  few  minutes.  About  an  liour  later  a  second  smaller 
dose  of  the  same  cathartic  is  given,  so  that  a  goofl  bowel 
movement  will  surely  result. 

To  Suyyort  the  Patient's  Strength. — During  the  period  of 
vomiting  it  is  well  to  have  an  assistant  preparing  a  bed  so 
that  the  patient  may  be  put  to  bed  when  the  stomach  is 
emptied. 

This  part  of  the  treatment  depends  largely  upon  the  char- 
acter of  the  poison  taken  and  the  symptoms  which  have 
developed — that  is,  the  treatment  is  largely  symptomatic. 

If  the  poison  has  caused  irritation  to  the  stomach  the  pain 
may  be  relieved  by  a  tablespoonful  of  olive  oil  and  by  the 
use  of  a  hot-water  bag.  If  there  is  shock,  apply  external 
warmth  and  stimulants.  If  the  patient  is  comatose,  as  from 
opium  poisoning,  slap  the  face  and  hands  with  cold  wet 
cloths  and  try  to  keep  him  awake.  If  there  are  convulsions, 
keep  the  patient  very  quiet  and  give  medicines,  such  as 
bromides  and  opium,  to  quiet  the  increased  activity  of  the 
nervous  system. 

The  diet  should  consist  entirely'  of  fluids,  especially  where 
an  irritant  poison  has  been  taken.  Quantities  of  water  should 
be  given  in  order  to  dilute  that  portion  of  the  poison  which 
has  been  absorbed,  and  must  later  be  excreted  through  the 
kidneys. 

Special  Poisonings. — There  are  many  hundreds  of  sub- 
stances which  act  as  poisons,  only  a  few  of  which  can  be 
discussed  in  detail.  In  such  cases  it  is  to  be  understood  that 
the  general  treatment  is  carried  out  along  the  plan  already 
outlined.  Some  of  the  more  common  poisons,  because  they 
are  frequently  met  with,  will  be  discussed  in  more  detail, 
attention  being  drawn  to  the  special  indications  for  treatment 
in  each  case. 

Caustic  Acids. — These  include  sulphuric,  hydrochloric, 
nitric,  and  many  other  acids.  In  poisoning  with  caustic 
acids  there  are  apt  to  be  burns  about  the  mouth  and  lips. 
The  irritation  of  the  stomach  is  marked  and  associated  with 
severe  abdominal  pains. 

When  you  see  a  case  of  acid  poisoning,  always  neutralize 
the  acid  with  some  form  of  alkali.     Bicarbonate  of  soda 


---  porsoxixa 

(onliiKirv  hakiuii;  soda)  is  to  be  found  in  every  household. 
It  should  be  given  in  solution,  one  or  two  teaspoonfuls  in  a 
glass  of  water.  Lime-water  or  milk  of  magnesia  can  some- 
times be  obtained.  They  may  be  given  in  full  strength  or 
slightly  diluted.  Borax  may  be  given  in  the  same  maimer 
as  bicarbonate  of  soda,  but  it  should  be  given  in  smaller 
doses  and  should  not  be  allowed  to  remain  in  the  stomach. 
Ammonia  is  another  alkali,  but  as  it  is  very  irritating,  it 
should  not  be  given  if  the  harmless  alkalies  are  available. 
Aromatic  spirits  of  anmionia  or  CN'en  household  ammonia, 
one  teaspoonful  to  a  glass  of  water,  makes  an  alkaline 
solution  which  may  be  used  to  neutralize  acid  ])oisons. 

Caustic  Alkalies. — Including  strong  ammonia,  potash, 
quicklime,  caustic  soda,  and  many  others. 

There  are  apt  to  be  burns  about  the  lips  and  mouth,  but 
they  are  much  less  noticeable  than  burns  caused  by  strong 
acids.  The  skin  has  a  characteristic  soapy  feeling  after  strong 
alkalies  have  been  applied. 

Any  dilute  acid  (except  carbolic  acid)  may  be  used  to 
neutralize  the  alkali.  Mnegar,  diluted  three  or  four  times, 
is  one  of  the  safest  and  is  almost  always  obtainable.  Sour 
milk,  which  contains  lactic  acid,  or  lemon  juice,  which  con- 
tains citric  acid,  may  })e  given.  If  obtainal)le,  sulphuric  or 
hydrochloric  acid  may  be  given  in  the  proportions  of  ten  to 
twenty  drops  of  the  concentrated  acid  to  a  glass  of  water. 

After  poisoning  with  either  acids  or  alkalies  the  pain  and 
burning  may  be  somewhat  relie\'e(l  by  small  doses  of  olive 
oil  at  frequent  intervals.  Of  course  if  the  acids  and  alkalies 
are  taken  in  dilute  solutions  there  will  be  no  local  burns, 
while  the  gastric  irritation  and  general  symptoms  will  occur 
later  and  be  less  marked. 

Carbolic  Acid. — Carbolic  acid,  or  phenol,  is  not  a  true 
acid  from  the  chemical  view-point.  Therefore  it  does  not 
neutralize  alkalies  and  is  not  neutralized  by  them.  When 
strong  carbolic  acid  is  applied  to  the  skin  it  causes  a  burn. 
Consequently  after  taking  strong  carbolic  acid,  burns  may 
be  noted  about  the  mouth.  If  the  5  per  cent,  solution,  that 
is,  the  one  commonly  used,  is  taken  the  general  symptoms 
\y[\\  occur,  but  there  is  no  local  burn.  The  characteristic 
odor  of  carbolic  acid  is  always  present. 


POISONING  223 

When  strong  carbolic  acid  (05  per  cent.)  is  applied  to  the 
skin  and  immediately  washed  oft'  with  alcohol  no  })urn 
results.  Advantage  is  taken  of  this  fact  in  carbolic  acid 
poisoning  and  the  stomach  is  washed  out  with  dilute  alcohol 
(10  to  20  per  cent.)-  Whisky  or  brandy  which  are  practi- 
cally 50  per  cent,  solutions  may  be  used  diluted  once  or  twice. 

A  case  has  recently  come  to  my  notice  in  which  a  man 
poured  strong  carbolic  acid  directly  into  his  eye  in  mistake 
for  boric  acid.  He  promptly  washed  out  the  eye  with  alco- 
hol, the  result  being  that  no  serious  injury  resulted.  Always 
remember  to  associate  in  your  mind  carbolic  acid  and  alcohol. 

Opium.' — The  patient  is  first  drowsy  and  later  unconscious. 
The  pupils  are  contracted  to  the  size  of  a  pin-head  or  smaller 
and  the  respiration  is  very  slow,  often  ten  or  less  per  minute. 
The  patient  can  sometimes  be  aroused,  but  soon  drops  off  to 
sleep. 

In  addition  to  the  general  treatment  the  patient  should 
be  kept  awake  by  striking  the  face  or  chest  with  cold  cloths 
or  by  shaking  him. 

It  is  never  necessary  to  keep  the  patient  walking  about, 
as  was  formerly  believed.  This  only  serves  to  exhaust  the 
strength  and  serves  no  useful  purpose. 

Chloral. — ^This  is  the  substance  which  is  found  in  "knock- 
out drops,"  and,  as  may  be  imagined  from  this  name,  it  acts 
very  quickly.  The  symptoms  are  marked  prostration, 
dilated  pupils,  shallow  respiration,  and  a  rapid  and  feeble 
pulse.  Coma  may  result.  Stimulation,  combined  with 
treatment  similar  to  that  for  shock,  should  be  promptly 
started.  The  giving  of  large  draughts  of  very  black  coffee  is 
one  of  the  best  methods  of  stimulation. 

Many  of  the  headache  and  sleeping  powders  contain  drugs 
very  similar  to  chloral,  and  consequently  the  treatment  of 
poisoning  with  any  of  these  drugs  is  practically  always  the 
same. 

Strychnin. — There  are  general  convulsions  very  similar 
to  epilepsy  or  tetanus.  There  may  be  severe  abdominal 
cramps.    The  patient  is  usually  conscious  to  the  end  and  dies 

1  Morphin  is  the  active  principle  of  opium  and  consequently  the  sjTiip- 
toms  of  poisoning  and  the  treatment  thereof  are  exactly  the  same. 


224  ruLSONlNG 

from  exhaustion  after  severe  convulsive  seizures.  As  these 
convulsions  may  be  broufjlit  on  by  a  sudden  noise  or  jar 
the  patient  should  be  kei)t  as  quiet  as  possible. 

I  have  seen  a  patient  who  had  taken  a  larjj;e  dose  of  strych- 
nin sent  off  into  convulsions  by  the  slamming  of  a  door  or 
by  simjily  touching!;  the  foot  of  the  bed.  Opium  or  bromides 
should  be  ^Wvn  in  larjiv  doses  if  they  are  at  hand. 

Belladonna. — Poisoning  with  belladonna  or  atropin,  which 
is  its  active  i)rinciple,  results  in  prostration,  with  full,  rapid 
pulse  and  dilated  pupils.  The  mind  is  hyperactive,  possibly 
showing  periods  of  delirium. 

I^limination  by  the  kidneys  and  bo\\'els  is  of  the  utmost 
importance.  Stimulation  by  hot  coffee  and  alcoholic  drinks, 
combined  with  the  ordinary  treatment  for  shock  and  alter- 
nating hot  and  cold  applications  to  the  face  and  chest,  are 
all  of  value. 

Bichloride  of  Mercury. — ^This  substance,  also  called  corro- 
sive sublimate,  is  frequently  taken  with  suicidal  intent.  The 
so-called  bichloride  tablets  are  antiseptic  tablets  contain- 
ing about  7-2"  grains  of  bichloride  of  mercury,  enough  to 
poison  several  adults. 

The  symptoms  are  burning  and  redness  of  the  mouth  and 
throat,  with  pain  and  irritation  in  the  region  of  the  stomach, 
possibly  associated  with  nausea,  vomiting,  and  diarrhea.  If 
the  i)atient  recovers  from  the  immediate  symptoms,  the 
mercury  being  absorbed  into  the  blood  must  be  excreted  by 
the  kidneys.  As  bichloride  of  mercury  is  very  irritating,  it 
gives  rise  to  acute  inflammation  of  the  kidneys,  so  that  they 
cease  to  fiuiction,  and  death  results  after  about  a  week  or 
ten  days. 

During  this  period  the  patient  apparently  recovers  com- 
pletely from  the  irritation  of  the  stomach  and  throat,  and 
the  third  or  fourth  day  he  may  consider  himself  well ;  later 
the  strength  is  gradually  lost  and  the  symptoms  of  nephritis 
develop.  If  the  amount  of  the  drug  absorbed  is  not  too  great 
recovery  results.  In  a  case  recently  seen  which  received 
prompt  treatment,  enough  of  the  mercury  was  removed  from 
the  stomach  so  that  the  nephritis  was  only  of  moderate 
degree,  the  patient  making  a  complete  recovery. 

The  treatment  should  aim  to  remove  as  much  of  the  poi- 


POISONING  225 

son  as  possible  before  absorption  takes  place.  Milk  forms'a 
temporary  combination  with  mercury  so  that  it  cannot  be 
absorbed,  but  this  must  be  removed  at  once  from  the  stom- 
ach. A  large  dose  of  salts  should  be  given  to  clear  out  the 
intestinal  canal  as  well.  Bearing  in  mind  the  dangers  of 
kidney  irritation,  a  large  quantity  of  water  should  be  given 
to  dilute  the  urine  as  much  as  possible,  so  as  to  minimize 
the  irritant  action  upon  the  kidneys. 

Acute  Alcoholism. — It  is  hardly  necessary  to  describe  the 
symptoms  of  the  milder  degree  of  acute  alcoholism.  Drunk- 
enness is  unfortunately  too  common  an  occurrence  to  require 
much  description.  Moreover,  first  aid  is  not  required  in 
the  earlier  stages,  the  intoxicated  person  being  well  satisfied 
with  his  condition. 

In  the  later  stages  where  voluntary  control  of  the  voice 
and  the  limbs  has  been  lost,  but  the  patient  is  still  conscious, 
the  patient  may  be  "sobered  up"  by  the  use  of  an  emetic, 
such  as  mustard  and  water  or  salt  and  water,  followed  by  a 
dose  of  salts  and  several  cups  of  hot  coffee.  It  is  surprising 
to  see  how  quiet  the  man  who  has  been  "fighting  drunk" 
becomes  after  he  has  been  given  an  emetic. 

Alcoholic  coma  is  more  serious  and  may  even  result  fatally. 
The  face,  commonly  flushed  and  bloated,  in  the  later  stages 
becomes  moist  and  pale.  The  pupils  are  dilated  and  the 
eyeballs  red  and  congested.  The  coma  may  be  complete,  but 
usually  the  patient  can  be  partially  aroused.  The  pulse  may 
be  slow  and  full,  but  in  the  later  stages  it  is  apt  to  be  rapid 
and  weak. 

There  is  always  a  strong  alcoholic  odor  to  the  breath, 
but  the  converse  is  not  always  true.  It  should  be  remem- 
bered that  a  person  who  is  comatose  from  apoplexy  or  fracture 
of  the  skull  may  have  been  drinking  and  consequently  have 
a  strongly  alcoholic  breath.  Be  careful  in  diagnosing  alco- 
holism to  rule  out  other  causes  of  unconsciousness.  ^Yhen 
in  doubt  between  alcoholism  and  apoplexy  always  treat  for 
the  latter,  in  which  case  vomiting  is  to  be  avoided. 

If  you  are  satisfied  that  you  are  dealing  with  acute  alcohol- 
ism, put  the  patient  to  bed,  and  if  the  patient  is  able  to  swal- 
low, give  a  good  dose  of  salts  and  apply  hot-water  bottles 
15 


226 


POISONIA^G 


al>()Ut  the  feet  niul  logs.  If  tlio  face  is  AusIumI  ;m  ice-cap  or 
cold  clotlis  may  he  i)lace(l  upon  the  hea(h  l>ut  if  the  face  is 
pale  this  is  imiiecessary.  As  long  as  the  condition  remains 
good  there  is  little  treatment  recpiired,  but  when  the  j^iilse 
is  weak  and  the  condition  described  under  shock  is  ])resent, 
black  coiVcc  should  be  gi\en  for  its  stinuilating  eiVect.  If  it  is 
imjiossible  to  make  the  patient  swallo\\',  the  colVee  may  be 
injected  into  the  rectum. 


\ilii/ 


Fig.  140. — Shuwing  thu  cuiiimuu  imislirooni  and  one  of  the  poisonous 
variety.  The  swollen  root  and  sac  like  envelope  mark  tlie  fungus  on  the  left 
as  poisonous. 

Naturally,  the  stomach  should  be  emptied  if  possible  by 
the  use  of  emetics  or  a  stomach-tube,  but  emetics  should  not 
be  given  if  the  i)atient  is  in  a  state  of  extreme  collapse. 

Chloroform  and  Ether.— If  the  drug  has  been  taken  by 
inhalation  no  special  .treatment  is  necessary.  Recovery 
begins  at  once  when  the  drug  is  stopped,  unless  too  great  a 
quantity  has  been  taken. 

Whei'i  taken  internally'  the  stomach  should  be  emptied 
and  the  patient  gi\'en  stimulation.     Artificial  respiration  is 


POISONING  227 

most  important  in  these  cases  })ecause  the  efl'eet  of  tlie  drug 
rapidly  passes  off. 

Mushroom  Poisoning. — There  are  a  variety  of  ])oisonous 
mushrooms.  Some  are  simjily  gastric  irritants  and  some  are 
general  or  systemic  poisons.  A  few  are  very  deadly.  Never 
collect  and  eat  any  fungus  unless  familiar  with  its  identifica- 
tion.    The  treatment  is  the  same  as  for  ptomain  poisoning. 

Ptomain  Poisoning. — Foods  which  are  partially  decomposed 
may  contain  poisons,  although  there  has  been  no  change  in 
their  taste  or  odor.  Milk,  fish,  and  meats  which  have  been 
allowed  to  stand  during  warm  weather  are  specially  prone 
to  contain  ptomains.  Canned  meats,  especially  when  kept 
for  several  days  exposed  to  the  heat  of  the  summer  sun, 
may  contain  large  quantities  of  poisons. 
■  Symptoms. — The  symptoms  do  not  make  their  appearance 
immediately  after  taking  the  poisonous  food.  There  is 
usually  a  period  of  an  hour  or  more  after  eating  during  which 
the  patient  has  no  symptoms.  Then  nausea  occurs,  associ- 
ated with  vomiting  and  followed  by  abdominal  cramps.  Later 
purging  begins  with  frequent  and  watery  movements.  As  a 
result  there  is  marked  prostration.  It  is  characteristic  of 
ptomain  poisoning  that  several  persons  in  the  same  family 
are  taken  violently  ill  at  about  the  same  time. 

Treatment.  —  The  treatment  consists  in  emptying  the 
stomach  as  soon  as  nausea  occurs.  When  a  person,  who 
has  been  perfectly  well,  suddenly  develops  nausea  after  tak- 
ing food  it  is  almost  a  certainty  that  something  in  the  food 
is  acting  as  a  poison,  and  the  sooner  the  stomach  is  emptied 
the  better.  Do  not  try  to  control  nausea  under  these  circum- 
stances, for  if  the  poison  enters  the  intestinal  canal  it  will 
cause  more  trouble  than  it  has  in  the  stomach. 

After  the  stomach  is  emptied  a  dose  of  castor  oil  should 
be  given,  or  if  this  is  not  at  hand  give  salts  or  some  other 
form  of  catharsis.  Meanwhile  the  patient  is  put  to  bed, 
warmth  applied,  and  stimulants  given  if  necessary.  In 
this  connection  it  may  be  noted  that  it  is  unwise  to  try  to 
check  an  acute  attack  of  diarrhea  before  giving  a  cathartic, 
preferably  castor  oil.  After  the  cathartic  has  had  time  to 
act,  paregoric  may  be  given  in  teaspoonful  doses  (for  an  adult) 
every  three  or  four  hours  in  order  to  control  the  diarrhea. 


22S 


POISONING 


Heady  Ueferexce  Table  of  Poisons  and  Antidotes. 

The  followinjj;  table  contains  sn^^estions  for  the  proper 
treatment  of  those  forms  of  poisoning;  most  hkely  to  occur: 


POISON. 

Nature  unknown 


Acidii— 
Sulphuric, 
Nitric, 

Hydrocliloric, 
Oxalic, 


Hijdrocijnnic    Acid    and 
Potassium  Cyanide    .  . 


Carbolic  Acid  and  Creo- 
sote   


Arsenic — 
Paris  Rrcen, 
Scheelc's  green, 
Fowler's  solulion, 


Acetate  of  Lead   . 


Mercury, 

Corrosive  sublimate, 
Antimony, 
Tartar  Emetic, 


Copper  Sails 


Phosphorus 


Nitrate  of  Silver      \ 
(lunar  caustic),  j 

Iodine 


TREATMENT. 

Provoke  repeated  vomiting; 

Ciive  bland  liijuids: 

Stimulate,  if  necessary  ;  keep  up  breathing. 

Give  an  alkali    (soap,  soda,  and  whitewash 
usually  at  hand  I ;  limewater;  magnesia; 

Provoke  vomiting;   avoid  stomaeh-i)umj); 

(iivc  ice  cream  and  bland  fluids; 

Secure  rest ;  relieve  pain  by  opium; 

Stimulate,  if  necessary; 

Feed  l)y  enema. 

Stomach-pump  or  emetic; 

Stimulate;  i>utassium  permanganate; 

Give  dilute  ammonia-water— by  intravenou.s 
I      injection,  if  necessary;  chlorine-water; 

Cold  allusions ; 
I.  Give  atropine,  gr.  bV.  hypodermatically. 
I  Give  l'4>som  salts,  dilute  sulphuric  acid  ;  atro- 
pine, hypodermatically; 
<  Stomach-pump  or  emetics  ; 

White  of  egg;  amyl  nitrite; 
[  Stimulate ;  artificial  heat. 

IGive  vinegar,  lemon-juice,  or  orange-juice,  or 
other  acid  or  a  lixed  oil ; 
Give  bland  liquids; 
Secure  rest ;  relieve  pain  by  opium ; 
Stimulate,  if  necessary. 
{Stomach-pump  or  emetics ; 
Give  hydrated  oxide  of  iron  or  dialyzed  iron 
and  magnesium  oxide ; 
Give  dose  of  castor  oil ; 
Secure  rest; 
Stimulate,  if  necessary. 

f  Stomach-pump  or  emetics ; 

(iive  Epsom  salt  or  dilute  sulphuric  acid; 
■!   Milk,  raw  eggs,  and  water; 

Morpliine  hypodermatically  for  i)ain; 
[  Potassium  iodide  to  eliminate  the  drug. 

{Emetics;  careful  lavage; 
Give  some  infusion  containing  tannic  acid  ; 
Give  raw  eggs  and  milk  ;  bland  liquids; 
Give  dose  of  castor  oil ; 
Stimulate,  if  necessary. 

iGivo  albumin  (milk,  raw  eggs);  yellow  prus- 
siate  of  p(jlas,-ium  ; 
Stomach-). unqi  or  emetics  ; 
Give  bland  fluids. 

(Provoke  vomiting  by  repeated  five-grain  doses 
of  sulphate  of  copper; 
Potassium  permanganate  (J-J  per  cent.) ; 
Give  dose  of  magnesium  o.xide,  but  no  oil. 
f  Give  strong  salt  and  water;  \  repeat  many 
I  Provoke  vomiting ;  J      times. 

C  Stomach-i)ump  or  emetics; 
■<  (Jive  gelatinized  starch  and  water; 
(.  Give  bland  fluids. 


POISONING 


229 


POISON. 

Opium- 
Morphiiie, 
Laudanum, 
Paregoric,  etc., 

Chloral—  \ 

Paraldehyde,  / 


ne,  > 
in,  j 


Nux  Vomica- 
Strychnine 
Picrotoxin 


Aconite—  \ 

Veratrum  viride,  j 
Hemlock,  'i 


Toadstool,  > 

Tobacco,  etc.,  etc.,) 
Belladonna  or  Atropine, 
Hyoscyamus  or  Hyoscyamine, 
Duboisia  or  Duboisine, 
Stramonium  or  Daturine, 

Alcohol , 


Decayed  Meat  or  Vegetables 


Poisonous  Gases—  1 

Carbonic  acid  or  oxide,   > 
Sulphuretted  hydrogen,  j 


TREATMENT. 

Stomafh-pnmp  ;  emetic;  potafisinm  per- 
miiiiK'nniic,  t)y  moutli ;  adnniiiliii  :  am- 
moiiiii ;  hut  strong  cofleehy  the  bowel ; 
atropine,  cocaine,  or  strychnine  hypo- 
dermatically  ;  oxygcn-inhalation.s  ;  ar- 
tificial respiration  ;  lingual  traction. 

Stomacn-pump  or  emetic  ;  artificial  heat ; 
massage;  stimulate;  stryclmine;  amyl 
nitrite ;  artificial  respiration. 

Stomach-pump  or  emetic  ;  animal  char- 
coal or  tannic  acid  ;  bromide  and  chlo- 
ral;  amyl  nitrite  ;  chloroform  by  inha- 
lation ;    artificial  respiration. 

Stomach-pump  or  emetic;  stimulate; 
heat;  atropine;  artificial  respiration. 

Provoke  vomiting  and  give  a  purge; 
tannic  or  gallic  acid ; 

Stimulate  well ;  keep  up  breathing. 

(Stomach-pump  or  emetic ;  stimulate ; 
Enema  hot  strong  coffee;  artificial  heat; 
morphine;      pilocarpine;      physostig- 
mine ;  artificial  respiration. 
f  Stomach-pump  or  emetic; 
t  Give  ammonia  and  water. 
Provoke  vomiting ;  wash  out  stomach  ; 
Give  a  purgative  ;  give  an  enema  ; 
Give  powdered  charcoal  and  hydrogen 

dioxide. 
Fresh  air ;  oxygen ; 
Artificial  respiration ; 
Amyl  nitrite  or  nitro-glycerin ; 
Stimulation. 


CHAPTER   XT. 
EMERGENCY  TREATMl^Nl^  OF  DISEASE. 

TiiK  first-aid  worker  may  be  called  on  for  advice  in  case 
(»f  illness  dne  to  disease.  Tims  a  ])atient  j^reviously  ])erfectly 
healthy  may  suddenly  develop  fever,  the  question  inmiedi- 
ately  arising  as  to  the  best  plan  of  management  of  the 
condition  imtil  a  ])hysician  can  be  secured.  A  man  known 
to  be  snlfering  from  kidney  disease  may  suddenly  have  a 
convulsion,  or  a  stranger  may  suddenly  fall  unconscious 
either  with  or  without  convulsions.  All  these  cases  have 
special  indications,  and  if  they  are  not  skilfully  treated 
disastrous  results  may  occur. 

1  have  in  mind  the  case  of  a  boy  who,  ^^  hile  suifering  from 
a  rather  mild  attack  of  influenza,  was  allowed  to  ride  about 
ten  miles  in  an  open  automobile  in  midwinter  to  see  a  phy- 
sician, the  result  being  that  pneumonia  developed,  which 
ended  fatally.  In  another  case  a  man  had  a  se^•ere  chill  due 
to  malaria.  As  there  were  no  means  of  transportation  he 
was  obliged  to  walk  home,  a  distance  of  about  two  miles. 
As  a  result  of  the  severe  strain  upon  his  heart,  death  resulted 
soon  after  he  reached  home. 

Even  a  slight  knowledge  of  the  emergency  treatiuent  of 
disease  would  have  prevented  both  of  these  deaths.  It  is 
not  expected  that  the  first-aid  student  will  be  able  to  diag- 
nose the  various  diseases  which  may  occur,  but  only  that  he 
will  recognize  certain  symptoms  which  commonly  occur  and 
that  he  will  outline  an  emergency  treatment  which  will,  at 
least,  do  the  patient  no  harm,  while  it  will  probably  do  much 
good. 

FEVER. 

A  rise  in  temperature  is  one  of  the  commonest  symptoms 
of  di-sease.  It  occurs  in  ordinary  colds,  bronchitis,  iuHuenza, 
local   cellulitis,   inflammation   of   the   intestines,   tonsillitis. 


CHILLS  231 

malaria,  and  in  numerous  other  diseases.  Often  when  a 
physician  first  sees  a  patient,  fever  is  the  only  symptom, 
the  characteristic  features  of  the  particular  disease  not 
becoming  evident  until  several  days  later. 

Symptoms. — Fever  may  be  recognized  by  a  flushed  face, 
a  sensation  of  weakness,  rapid  pulse,  and  increased  body 
temperature  (shown  by  the  clinical  thermometer).  A  tem- 
perature from  100°  to  101°  F.  indicates  a  mild  fever,  from 
101°  to  103°  F.  is  a  moderate  rise,  and  temperatures  of  103° 
F.  or  above  are  considered  high.  Every  first-aid  student 
should  be  accustomed  to  the  use  of  the  clinical  thermometer. 

Treatment. — ^The  treatment  consists  of  rest,  preferably  in 
bed,  and  in  the  strict  avoidance  of  exposure  or  muscular 
fatigue.  To  allow  a  person  with  fever  to  go  out  in  the  cold 
and  wet  or  to  continue  his  work  is  nothing  less  than  criminal. 
Many  cases  of  pneumonia  and  other  serious  conditions  can 
be  avoided  if  febrile  patients  are  put  to  bed  at  once. 

In  the  United  States  Army,  where  the  soldiers  receive 
free  medical  treatment  and  do  not  lose  their  pay  when  sick, 
serious  disease  conditions  are  often  prevented,  because  it  is 
the  custom  to  send  soldiers  who  have  the  slightest  fever  to 
the  hospital  at  once.  In  private  life,  on  the  other  hand, 
men  struggle  to  fight  oflf  the  impending  illness  mainly 
because  their  pay  stops  when  they  are  away  from  work, 
the  consequence  being  that  they  struggle  on,  continually 
growing  sicker  and  weaker,  until  they  are  finally  obliged  to 
stop,  the  condition  then  being  much  more  serious  than  the 
original  complaint. 

In  addition  to  rest  a  cathartic  may  be  safely  prescribed 
and  the  patient  put  on  a  fluid  diet.  He  should  be  encour- 
aged to  drink  water  freely.  In  many  cases  of  influenza,  or 
mild  gastro-intestinal  fever,  the  treatment  above  will  result 
in  a  complete  cure  within  a  few  days. 

CHILLS. 

When  the  temperature  rises  suddenly  the  patient  has  a 
chill,  when  it  falls  he  sweats  profusely;  consequently,  if  a 
patient  complains  of  marked  chilliness,  or  if  there  is  a  real 


232 


EMEROEXCY   TREATMEXT  OF   DISEASE 


chill,  we  may  siisi)oct  that  the  toni])erature  is  risinjj,  and 
conversely  when  a  febrile  patient  breaks  into  a  sweat  we 
may  conclude  that  the  temperature  is  falling,'. 

In  malaria  this  process  is  clearly  shown.  There  is  first  a 
chill,  during  which  the  sufferer  comjilains  of  extreme  cold, 
followed  by  a  short  period  of  high  temperature,  in  which 
the  symptoms  of  fever  are  present.  After  a  few  hours  the 
body  breaks  out  into  a  sweat  and  the  temperature  falls  again. 
^Vhen  the  temperature  reaches  normal  the  ])atient  feels 
weak,  but  otherwise  perfectly  well. 


DAY  OF 
MONTH 

10 

11 

12 

13 

14 

15 

TIME  OF 
DAY 

^':M^I^Mi 

jUl^liMi 

jM.'^Ij|.Mi 

iWi\^^, 

^M^m 

4z  z  i 

105" 

'5"  101" 

£  103" 
S  102" 
?  101" 
S  100° 
S    99° 
^    9«= 

-=^y\ 

:-    \    : 

-'■     R     ■"'    ■ 

zJ     \: 

;     \ 

:    l\c, 

■     i        \ 

:       V 

il:     I  : 

\ 

-ll    '-.  -  \:    - 

\ 

:  '■-  V- 

'■r  '■-'  \ 

\ 

\1                   \ 

..^^       , 

~^-h  '.  - 

V            K^     ,       .*^ 

V^:  . 

Fig.  141. — Temperature  chart  in  malaria,  showing  the  course  of  the  fever 
with  chills  every  other  day.  Notice  that  the  rise  of  temperature  is  of 
short  duration.     (Osier.) 

Chills  may  occur  at  the  onset  of  any  acute  fever  (espe- 
cially pneumonia),  and  are  of  common  occurrence  in  malaria 
and  septicemia  (blood  poisoning). 

Symptoms. — The  symptoms  during  a  chill  are  a  sense  of 
extreme  cold,  e^'en  when  in  warm  surroundings,  together  with 
a  rapid  pulse,  weakness,  and  a  rising  body  temperature.  The 
hands  and  feet  are  cold  and  the  face  is  pale  or  even  blue. 

Treatment. — The  treatment  consists  of  rest  in  bed  with 
as  many  covers  as  are  desired  and  several  hot-water  bottles 
applied  about  the  body.  Hot  cofl'ee  and  hot  broth  may  be 
given  freely.  As  soon  as  the  febrile  stage  is  reached,  as  shown 
by  the  flushing  of  the  face  and  the  warmth  of  the  hands  and 
feet,  the  extra  covers  and  hot-water  bottles  should  be 
removed  from  the  bed.    Should  sweating  occur  it  should  be 


EPILEPSY  OP.  FITS  233 

allowed  to  proceed  for  about  half  an  hour,  and  then  the 
body  should  be  well  dried  with  a  warm,  rough  towel  and 
warm,  dry  clothing  put  on.  Of  course  no  patient  who  is 
suffering  from  any  stage  of  a  chill  should  be  allowed  to  con- 
tinue at  work  or  to  be  exposed  to  cold  or  wet. 

CONVULSIONS. 

Convulsions  occur  in  many  different  conditions.  They  are 
seen  frequently  in  epilepsy,  nephritis,  and  injury  to  the 
brain.  In  young  children  convulsions  are  more  common  than 
in  adults,  frequently  occurring  instead  of  a  chill  at  the  onset 
of  an  acute  fever.  In  an  adult  previously  well  and  suddenly 
seized  with  a  convulsion  the  first  thing  to  suspect  is  an 
epileptic  fit.  Next  in  frequency  are  apoplexy,  fractured 
skull,  and  nephritis.  In  a  child  a  "spasm"  usually  means 
an  acute  fever  or  gastro-intestinal  disease.  In  later  child- 
hood, that  is,  after  puberty,  convulsions  are  less  common, 
epilepsy  being  practically  the  only  cause  of  this  condition. 

Treatment. — In  the  case  of  a  convulsive  seizure  of  unknown 
origin  a  physician  should  be  sent  for  at  once  and  the  patient 
prevented  from  doing  himself  harm.  The  clothing  should 
be  opened  at  the  neck  and  the  patient  placed  quietly  in  bed. 
If  the  face  is  flushed,  apply  an  ice-cap  or  cold  compress  to  the 
head.  If  the  face  is  pale,  external  heat  may  be  applied. 
When  the  patient  is  able  to  swallow,  a  dose  of  salts  should 
be  given.  Nurses  and  trained  attendants  are  usually  per- 
mitted to  give  a  few  whiffs  of  chloroform  or  a  hypodermic  of 
morphin  to  a  patient  having  a  prolonged  convulsion.  While 
the  use  of  these  powerful  drugs  without  an  order  from  a 
physician  is  generally  not  permitted,  it  might  be  justified  in 
such  cases.  Fortunately,  in  most  cases,  convulsions  are  of 
short  duration  and  little  need  be  done.  After  the  spasm 
has  ceased  a  cathartic  should  be  given  and  the  patient  kept 
quiet  and  warm  between  blankets. 

EPILEPSY    OR   FITS. 

In  common  parlance  the  term  "fits"  refers  to  epileptic 
convulsions.    These  are  due  to  a  state  of  increased  nervous 


2:U  EMERCEXCY    TREATMEXT  OF    DISEASE 

iri'itiibility  of  the  hraiii,  tlu'  cause  of  which  is  not  clearly 
understood. 

Symptoms. — A  person  who  is  subject  to  epilepsy  can  gen- 
erally tell  when  an  attack  is  about  to  occur  by  a  peculiar 
.sensation  which  he  experiences.  Followin.i;  this  the  face 
becomes  ])ale  antl  the  eyes  dull  and  starin<i. 

The  attack  usually  begins  with  a  sharp  cry,  possibly  a 
piercing  shriek,  following  which  the  sufferer  falls  unconscious 
to  the  ground.  The  entire  body  is  first  held  rigid,  tlie  face 
becomes  congested,  the  tongue  may  l)e  bitten  and  bleed, 
and  the  eyes  are  turned  upward.  Convulsive  movements 
start,  often  in  the  hands  and  feet,  soon  spreading  to  the 
entire  body.  The  attacks  rarely  last  for  more  than  a  few 
minutes,  but  several  attacks  may  follow  each  other  with 
only  short  intervals.  After  the  attack  the  ])atient  lies  back 
relaxed  for  several  minutes  before  he  opens  his  eyes  and 
answers  questions.  At  first  he  is  dull,  the  mind  clouded, 
and  if  left  alone  he  will  sleep  for  an  hour  or  more.  Very 
ran^ly  after  an  attack  he  may  be  excited  and  ^'iolent. 

Treatment. — The  patient  should  be  allowed  to  lie  flat 
wherever  the  fit  occurs,  care  being  taken  to  see  that  he  does 
not  injure  himself.  A  folded  coat  or  pillow  may  be  placed 
under  the  head  and  there  should  be  just  sufficient  restraint 
to  prevent  the  patient  injuring  himself  against  sharp  stones 
or  other  hard  objects  nearby. 

If  there  is  a  tendency  to  bite  the  tongue  a  folded  hand- 
kerchief or  a  cork  may  be  held  between  the  teeth. 

Do  not  attempt  to  give  stimulants,  for  swallowing  is  impos- 
sible, and  fluid  introduced  into  the  mouth  is  apt  to  enter 
the  windpipe  and  cause  strangulation.  Do  not  attempt  to 
"  break  the  grip"  or  forcibly  to  prevent  the  convulsion.  Such 
an  action  accomplishes  no  good  i)urpose  and  may  even  cause 
injury. 

After  the  fit  is  over  the  patient  should  be  allowed  to  sleep 
for  several  hours  in  a  cool  room.  If  the  patient  is  violent 
following  the  convulsion,  manual  restraint  should  be  resorted 
to.  Bromides  are  gi\'en  to  prevent  the  recurrence  of  the 
attacks. 


CONVULSIONS  IN  CHILDREN  235 

CONVULSIONS   IN    CHILDREN. 

As  has  been  mentioned  before,  these  attacks  in  young 
children  are  sometimes  due  to  disturbance  of  the  gastro- 
intestinal tract,  or  they  may  occur  at  the  beginning  of  an 
acute  disease.  Severe  irritation  of  the  bowels,  such  as  is 
caused  by  the  eating  of  a  large  quantity  of  berries,  is  a  fre- 
quent cause,  so  that  many  of  the  cases  are  seen  in  the  country 
during  the  wild-berry  season. 

Some  children  are  specially  prone  to  convulsions,  an  attack 
occurring  at  the  onset  of  every  febrile  attack.  The  habit  is 
usually  outgrown  by  the  end  of  the  fifth  year.  While  the 
appearance  of  a  convulsion  in  a  child  always  causes  great 
alarm,  the  child  is  really  in  little  danger,  serious  consequences 
being  extremely  rare. 

Treatment. — ^The  treatment  consists  in  remedies  which 
decrease  the  irritability  of  the  nervous  system,  combined 
with  those  which  quickly  empty  the  intestinal  canal.  The 
first  of  these  indications  may  be  met  by  the  use  of  a  warm 
bath  or  by  wrapping  the  child  in  a  blanket  previously  wet 
with  hot  water,  care  being  taken  not  to  burn  him.  A  cold 
cloth  may  be  placed  on  the  head.  To  empty  the  intestinal 
canal,  two  or  three  teaspoonfuls  of  castor  oil  may  be  given 
as  soon  as  the  child  is  able  to  swallow.  If  possible  an  enema 
should  be  given  at  once. 

When  the  convulsion  is  over  the  child  should  be  put  to 
bed  and  kept  perfectly  quiet  in  a  darkened  room.  Any 
attempt  to  move  him,  or  unusual  noises  or  excitement,  may 
cause  a  recurrence  of  the  convulsion.  Nothing  but  water 
should  be  given  by  mouth  for  at  least  twenty-four  hours. 


CHAPTER    XII. 
COMMON  EMERGENCIES. 

There  are,  in  addition  to  the  injuries  and  diseases  already 
discussed,  many  minor  emergencies  which  may  be  greatly 
relieved  by  intelligent  first  aid.  In  the  following  pages 
several  of  the  more  common  conditions  will  l)c  described 
and  the  emergency  treatment  outlined. 

The  mistake  should  not  be  made  of  supposing  that  the 
following  pages  describe  fully  all  the  necessary  treatment  for 
any  given  case.  The  treatment  outlined  is  emergency  treat- 
ment only  and,  if  the  condition  is  severe,  should  not  lead  to 
a  false  sense  of  security. 

In  most  cases  the  complaint  requiring  treatment  is  only 
a  symptom,  and  is  treated  as  such.  Thus,  nausea  might  be 
due  to  poisoning,  to  gastritis,  to  appendicitis,  and  to  numer- 
ous other  conditions.  Consecpiently,  the  treatment  for 
nausea  does  not  usually  cure  the  original  disease  but  only 
relieves  the  patient  temporarily  until  professional  advice 
may  be  secured.  On  the  other  hand,  in  some  cases  the  relief 
of  nausea  would  cure  the  disease.  For  exami^le,  if  the  nausea 
is  due  to  mild  ptomain  poisoning  the  relief  of  the  nausea  by 
\'omiting  results  in  cure.  Howe^'er,  it  must  be  emphasized 
that,  while  treatment  will  sometimes  result  in  complete 
recovery  it  is  wiser  except  in  very  mild  cases,  to  secure 
professional  advice  whenever  possible. 

HEADACHE. 

Headache  is  one  of  the  commonest  forms  of  pain  which 
rer[uires  relief.  It  may  be  due  to  eye-strain,  to  indigestion,  to 
constij)ation,  and  to  many  other  conditions.  Persistent 
headache  is  frequently  the  result  of  kidney  disease. 


TOOTHACHE  237 

Treatment. — The  treatment  depends  largely  upon  the 
cause.  It  is  usually  advisable  to  give  a  cathartic  even  if 
there  is  no  constipation.  This  is  because  there  may  be  jioi- 
sons  in  the  intestinal  canal  which  are,  to  a  certain  degree, 
responsible  for  the  headache. 

The  patient  should  be  put  to  bed  in  a  darkened  room,  a 
cold  compress  or  an  ice-cap  applied  to  the  head,  and  allowed 
to  sleep  if  possible.  I  have  had  patients  who  invariably 
secured  relief  if  they  drank  several  glasses  of  water,  and 
others  who  were  equally  certain  that  a  hot  foot-bath  relieved 
the  pain.    Both  of  these  simple  remedies  may  be  tried. 

If  there  are  symptoms  of  indigestion  a  quarter  of  a  tea- 
spoonful  of  bicarbonate  of  soda,  dissolved  in  water,  or  a  few 
soda-mint  tablets,  may  be  taken.  The  ordinary  Seidlitz 
powder  "settles"  the  stomach  and,  at  the  same  time,  acts  as 
an  efficient  cathartic. 

The  various  headache  powders  which  are  widely  adver- 
tised contain  drugs  that  depress  the  heart.  None  of  them 
are  free  from  danger. 

Aspirin,  5  grains,  or  phenacetin,  5  grains,  are  less  harmful 
than  most  of  the  advertised  remedies.  The  dose  may  be 
repeated,  once  if  necessary,  after  an  interval  of  an  hour  or 
more. 

TOOTHACHE. 

The  surest  way  to  prevent  toothache  is  to  prevent  decay 
of  the  teeth.  The  teeth  should  be  well  cleansed,  preferably 
after  every  meal,  but  at  least  twice  a  day.  A  good,  stif? 
brush  and  a  suitable  powder  or  paste  should  be  used  in  order 
to  thoroughly  cleanse  every  crevice  about  and  between  the 
teeth.  Dental  floss  passed  between  the  teeth  will  remove 
many  particles  of  food  which  cannot  be  reached  by  the 
brush. 

Toothache  may  be  due  to  irritation  of  an  exposed  nerve, 
either  by  the  acid  formed  in  fermenting  or  decomposed  food, 
or  by  heat  or  cold;  or  the  ache  may  be  the  result  of  an  actual 
infection  about  the  root  of  the  tooth  (ulcerated  tooth). 

Treatment. — The  treatment  begins  with  the  thorough 
cleansing  of  the  tooth  cavity  with  a  toothpick  swab,  formed 


238.  COMMON  EMERGENCIES 

l)y  w  r;ii)])iii<];  a  small  piece  of  absorbent  cotton  about  tlic  end 
of  an  ordinary  toothiiick.  AVhon  the  cavity  is  clean  a  small 
wad  of  cotton,  previously  dipped  in  oil  of  cloves,  or  strong 
phenol,  should  be  ])laced  directly  in  the  cavity. 

Counter-irritation  may  be  applied  to  the  gum  adjoining 
the  tooth.  For  this  purpose,  tinctin-e  of  iodin,  painted  on  the 
gum,  or  a  toothache  plaster  may  be  used.  A  piece  of  cotton 
wet  with  s])irits  of  cam])hor  and  placed  between  the  gum 
and  the  cheek  is  a  very  satisfactory  method  of  securing 
counter-irritation. 

In  addition,  a  hot-water  bag  or  hot  cloths  may  be  ])laced 
against  the  cheek  over  the  afl'ected  tooth. 

The  treatment  as  outlined  above  will  often  relieve  the 
pain,  but  it  is  important  that  a  dentist  should  be  seen  and 
the  tooth  receive  adequate  treatment  as  soon  as  possible. 

When  true  infection  is  present  the  tooth  is  commonly 
said  to  be  "ulcerated."  This  means  that  there  is  a  little 
abscess  at  the  root  of  the  tooth.  When  a  tooth  is  exquis- 
itely painful  and  the  surrounding  gum  tender  to  touch  it  is 
probably  ulcerated.  This  condition  may  exist  in  a  tooth 
which  is  apparently  satisfactorily  filled  and  is  apt  to  progress 
steadily  until  the  pus  points  or  the  tooth  is  extracted. 

The  treatment  for  an  ulcerated  tooth  is  the  same  as  for 
toothache.  A  dentist  can  often  relieve  the  pain  by  boring  a 
hole  down  through  the  center  of  the  tooth  and  allowing  the 
pus  to  escape.  When  the  condition  progresses  until  the  i)us 
points  (gum  boil)  the  abscess  may  be  opencfl  by  a  physician. 
The  after-treatment  depends  on  how  badly  the  root  has 
been  injured.  A  skilful  dentist  will  sometimes  save  the 
tooth. 

NEURALGIA. 

Neuralgia  ^\'hen  occurring  in  the  face  may  be  mistaken 
for  toothache.  It  may  be  due  to  some  sort  of  nerve  irrita- 
tion, as  from  a  decayed  tooth,  or  from  a  foreign  body  in 
the  nose;  or  it  may  occur  without  apparent  cause.  The  i)ain 
is  limited  to  one  side  of  the  face  and  the  attacks  are  apt  to 
recur,  more  or  less  frequently,  in  persons  subject  to  the 
disease. 


CON, J  uNcri  VI  Tfs  2:-;9 

Treatment. — Hot  applications  usually  afl'ord  j-clicf.  Hot- 
water  bags,  hot  compresses,  or  heat  in  any  form  may  be 
applied.  In  a  few  cases  cold  cloths  or  an  ice-cap  are  more 
grateful  to  the  patient.  Counter-irritation  with  oil  of  winter- 
green  or  menthol  will  give  relief  in  some  cases.  Aspirin  or 
phenacetin  used  as  outlined  under  Headache  may  be  tried. 
Many  cases  are  so  severe  and  persistent  that  they  are  relieved 
only  with  great  difficulty. 

EARACHE. 

Earache  usually  occurs  as  a  result  of  a  "cold,"  the  pain 
being  caused  by  the  collection  of  mucus  within  the  ear, 
which,  in  turn,  causes  pressure  on  the  sensitive  eardrum. 

Treatment. — In  the  early  stages,  before  the  pain  becomes 
severe,  the  condition  may  be  relieved  by  the  external  appli- 
cation of  heat.  A  hot- water  bag  may  be  held  to  the  side  of 
the  head  or  a  small  bag  of  salt  or  sand  thoroughly  warmed 
may  be  put  against  the  ear. 

If  the  pressure  of  the  mucus  is  sufficient  the  eardrum  may 
rupture.  This  will  be  shown  by  the  discharge  of  a  few  drops 
of  bloody  mucus  or  pus  and  the  immediate  relief  of  pain. 
If  this  occurs  the  ear  should  be  carefully  washed  out  by 
syringing  it  several  times  daily  with  a  warm  boric  acid  solu- 
tion (4  per  cent.),  care  being  taken  to  have  the  syringe  and 
the  solution  sterile. 

An  earache  should  never  be  neglected,  especially  if  asso- 
ciated with  fever.  Spreading  of  the  infection  from  the  ear 
to  the  surrounding  bone  may  result  in  mastoiditis.  Conse- 
quently, a  physician  should  always  be  summoned  when  an 
earache  is  at  all  severe. 

In  children  the  pain  of  a  decayed  tooth  will  sometimes  be 
mistakenly  referred  to  the  ear. 

CONJUNCTIVITIS. 

Conjunctivitis  is  associated  with  redness  and  congestion 
of  the  eyeball  and  the  inner  surface  of  the  lids.  There  is 
usually  a  slight  burning  sensation  and  the  eyes  are  sensitive 
to  bright  light. 


240    ■  COMMOX  EMERGENCIES 

It  may  occur  after  sunburn  or  exposure  to  extreme  lieat 
or  irritatiiij;  fjases.  An  infectious  t\»pe  (pink-eye)  may  occur 
in  one  or  hoth  eyes,  either  alone  or  associated  with  a  cold 
in  the  head. 

Treatment. — The  milder  cases  may  be  treated  by  the  ap])li- 
cation  of  cold  compresses  to  the  eyes.  These  are  ])repared  by 
foldin.s;  small  pieces  of  ijauze.  or  soft  linen,  into  two-inch 
scpiares,  three  or  four  layers  in  thickness.  Several  of  these 
compresses  are  prepared  and  placed  either  on  a  piece  of  ice  or 
in  ice-water.  The  excess  of  water  is  squeezed  from  one  of  the 
compresses,  which  is  then  ])laced  on  the  closed  eye.  After 
remaining  in  place  for  about  two  minutes  the  compress  is 
rem()\-ed  and  again  placed  in  the  ice-water,  ^^'l^ile  a  fresh 
compress  is  placed  upon  the  eye.  This  may  be  done  by  the 
patient  or  by  someone  else.  It  should  be  kept  up  for  about 
twenty  to  thirty  minutes  and  repeated  three  or  four  times 
daily.  In  addition,  the  eyes  should  be  washed  out  several 
times  daily  with  boric  add  solution  (2  to  4  per  cent.).  Never 
use  a  poultice  of  any  kind  upon  the  eye  nor  bandage  on  a 
wet  compress. 

STYE. 

A  stye  is  an  infection  of  one  of  the  hair  roots  of  the  eye- 
lash. It  is  ])ractically  a  small  boil.  In  the  early  stages  it 
may  be  sometimes  driven  away  by  the  use  of  cold  com- 
])resses  or  by  bathing  the  eye  with  very  cold  water.  When 
partially  develoi)ed  hot  compresses  are  preferred.  They  are 
used  in  the  same  manner  as  the  cold  compresses  referred  to 
above,  except  that  they  are  kept  in  hot  water  instead  of 
cold.  The  water  should  be  tested  with  the  hands.  If  the 
compresses  can  be  squeezed  out  without  burning  the  hands 
they  cannot  injure  the  eyes. 

As  the  stye  becomes  fully  developed  it  should  be  opened 
by  a  physician  to  allow  the  i)us  to  escape. 

BOILS. 

Boils,  or  furuncles,  are  very  common  about  the  back  of 
the  neck,  but  they  may  occur  anywhere  upon  the  body,  A 
boil  begins  as  an  infection  about  the  root  of  a  hair  and  occurs 


BOILS 


241 


with  especial  frequency  on  the  back  of  the  neck,  because  at 
this  point  the  neck  is  apt  to  be  irritated  by  a  starched  collar. 
For  this  reason  they  occur  in  this  location  almost  invariably 
in  men. 

When  the  pus  from  a  boil  is  rubbed  on  the  skin  the  infec- 
tion is  introduced  at  another  point  and  a  second  boil  results. 
In  this  manner  a  single  boil  is  apt  to  result  in  several  rein- 
fections, the  pus  from  the  first  boil  contaminating  the  collar 
of  the  coat  or  overcoat,  which  infects  the  neck  at  a  new  spot. 


■ 

HI 

^^m  "^ 

^^r  4)  -js^^^ 

^^^^H 

^r^.-.-«„ ,,_  ..^ 

ij^l 

:^i<^-  ^. 

^^H 

Fig.  142. — Carbuncle  of  the  neck  of  two  weeks'  duration.     Shows  Httle 
tendency  to  heal.     (Ashhurst.) 

Treatment. — ^Wlien  the  boil  first  appears  it  may  be  some- 
times cured  by  inserting  a  sharp-pointed  toothpick  dipped 
in  phenol  (95  per  cent.)  into  the  center  of  the  boil  for  about 
one-eighth  of  an  inch.  If  this  is  not  successful  the  boil 
should  be  opened.  It  is  never  necessary  to  wait  for  it 
to  point.  The  earlier  the  boil  is  incised  the  sooner  it  will 
get  well.  If  a  physician  is  not  available  a  continuous  wet 
dressing  of  boric  acid  may  be  applied.  This  acts  as  a  poul- 
16 


242       '  COMMON  EMERGENCIES 

tice  an(l  tends  to  cause  the  infection  to  point,  but  it  is  much 
inferior  to  treatment  by  incision. 

In  order  to  prevent  reinfection  a  starched  collar  should 
not  be  worn  until  the  boil  has  entirely  disapi:)eared,  and  great 
care  should  be  taken  to  i)revent  the  ])us  contaminating  the 
collar  of  the  coat  or  overcoat.  In  a  few  cases  boils  occur  as 
an  early  sign  of  diabetes. 

CARBUNCLE. 

This  is  a  local  infection  similar  to  a  l)oil,  but  much  more 
severe.  It  is  really  a  multiple  Ijoil.  Carbuncles  occasionally 
occur  as  a  complication  of  diabetes. 

The  surface  of  the  carbuncle  shows  several  openings,  each 
exuding  pus.    The  condition  tends  to  spread  rapidly. 

Treatment. — A  wet  dressing  of  boric  acid  solution  may  be 
applied  until  a  physician's  services  can  be  secured.  Most 
physicians  excise  the  entire  carbuncle. 

HICCOUGH. 

This  is  due  to  the  spasmodic  contraction  of  the  diaphragm, 
the  large  flat  muscle  which  separates  the  chest  from  the 
abdomen.  It  is  usually  due  to  irritation  of  the  stomach 
following  the  ingestion  of  too  much  or  unsuitable  food. 

If  a  deep  breath  is  taken  the  diaphragm  is  forced  down- 
ward and  the  spasmodic  contraction  cannot  take  place. 
Consequently,  if  the  breath  is  held  as  long  as  possible  the 
hiccough  may  not  recur.  Sometimes  a  little  plain  or  car- 
bonated water  will  stop  hiccoughs.  A  few  soda-mint  tablets 
or  a  little  hot  ginger  tea  may  relieve  the  indigestion  and  thus 
relieve  the  spasm.  If  these  methods  fail  and  the  hiccough 
is  troublesome  and  persistent  the  patient  should  be  made 
to  vomit,  thus  removing  the  cause  of  the  irritation. 

SORE   THROAT. 

This  condition  may  occur  associated  with  a  generalized 
inflammation  f)f  the  respiratory  passages  as  part  of  a  cold, 
or  it  may  be  due  to  tonsillitis  or  diphtheria. 


HOARSENESS  243 

Treatment. — A  hot  alkaline  gargle  of  bicarbonate  of  sofla 
or  borax  is  one  of  the  best  methods  of  treating  a  sore  throat 
of  doubtful  origin.  Sodium  bicarbonate  solution  made  by 
dissolving  one  teaspoonful  of  the  powdered  drug  in  a  glassful 
of  water  makes  a  solution  of  the  proper  strength.  Borax 
may  be  used  in  the  same  proportions.  These  solutions  are 
soothing  and,  being  used  hot,  tend  to  stimulate  the  tissues 
and  aid  healing. 

In  addition,  a  cold  compress  should  be  applied  to  the 
throat.  This  is  arranged  as  follows:  A  soft  piece  of  flannel, 
folded  so  that  it  is  about  three  inches  wide  and  just  long 
enough  to  reach  about  the  neck,  is  wrung  out  of  ice-water 
and  fastened  snugly  with  safety  pins  about  the  neck.  A 
second  piece  of  dry  folded  flannel,  a  little  larger  than  the 
first,  is  wrapped  about  the  wet  compress  and  pinned  at  the 
back.  If  flannel  cannot  be  obtained  a  soft  piece  of  linen  or 
cotton  can  be  used.  An  old  piece  of  toweling  serves  admir- 
ably in  an  emergency. 

In  about  twenty  minutes  the  compress  will  be  warm, 
acting  as  a  poultice.  It  is  advisable  to  change  the  compress 
every  hour  or  two  during  the  day,  but  it  is  not  necessary  to 
disturb  the  dressing  during  the  night. 

As  in  other  similar  infections  a  cathartic  may  be  given  at 
the  onset  of  the  disease. 

COLDS. 

At  the  onset  of  an  acute  cold  the  infection  can  often  be 
cured  by  a  hot  foot-bath,  and  a  hot  lemonade,  combined  with 
rest  in  bed.  In  addition,  active  catharsis  with  castor  oil  or 
salts  is  indicated.  Water  should  be  taken  freely,  increasing 
sweating  and  urination  and  thus  aiding  elimination. 

A  little  vaselin  placed  in  each  nostril  will  relieve  the 
breathing.  This  is  soothing  to  the  inflamed  mucous  mem- 
brane, and  tends  to  assist  healing. 

HOARSENESS. 

This  is  due  to  inflammation  of  the  vocal  cords  (laryngitis). 
It  may  occur  as  a  result  of  irritating  gases  or  as  a  result  of 


244  COMMOX  EMERCEXCIES 

overstrain,  as  after  iiroloiiiied  talking  or  clieeriiiji;.  Ordi- 
narily it  occurs  as  jKirt  of  an  acute  infection  (coKls,  tonsillitis, 
bronchitis,  etc.)- 

Treatment. — The  same  treatment  should  he  carried  out 
as  outlined  under  Colds.  Tlie  voice  should  he  rested,  talking 
being  avoided  as  much  as  possible. 

Inhalations  of  steam  are  most  soothing.  They  may  be 
given  by  arranging  a  paper  funnel  over  the  nozzle  of  a  kettle 
and  inhaling  the  steam.  A  teasi)oonful  of  com])ound  tincture 
of  benzoin  added  to  the  boiling  \vater  makes  the  steam  more 
etl'ective. 

Syrup  of  ipecac,  15  drops  every  two  or  three  hours,  and 
a  cold  compress  applied  to  the  throat  may  be  used  in  addition 
to  the  inhalations. 

SPASMODIC   CROUP. 

This  is  Avhat  is  ordinarily  known  as  "croup."  It  occurs 
in  children  and  is  due  exactly  to  the  same  factors  which 
cause  laryngitis  in  an  adult.  Some  children  have  croup 
with  every  cold. 

During  the  day  the  mother  notices  that  the  child  is  hoarse 
and  a  little  feverish.  There  is  apt  to  be  a  sharp,  ringing 
cough. 

Symptoms. — The  attacks  occur  at  night,  the  child  waking 
suddenly  and  becoming  alarmed  because  breathing  is  difh- 
cult.  The  fear,  together  with  the  difficult  respiration,  makes 
the  spasm  worse  and  consequently  aggravates  the  condition. 
There  is  usually  a  ringing  cough  and  insjnration  is  accom- 
panied by  a  sharp,  crowing  sound.  The  child's  face  may  be 
blue  in  color  and  the  whole  condition  most  alarming. 

Treatment. — Spasmodic  croup,  while  serious,  never  ends 
fatally,  the  attack  always  subsiding  before  morning.  The 
attack  can  often  be  pre\-ented  if  a  cathartic  is  given  in 
the  evening  when  the  first  symptoms  of  a  croupy  cough  are 
noticed.  The  child's  fears  should  be  quieted  and  the  bed 
placed  in  a  room  where  the  air  is  warm  and  moist. 

A  "croup  tent"  is  an  excellent  means  of  j^reventing  or 
treating  croup.  It  is  made  by  dra])ing  a  sheet  over  the  head 
of  the  bed  in  such  a  manner  that  the  child  is  covered  with  a 


SPASMODIC  CROUP  245 

small  improvised  tent.  An  alcohol  stove  and  a  small  kettle 
are  so  arranged  on  the  floor  that  the  steam  from  the  })oi]iiig 
water  passes  into  the  tent,  the  child  breathing  tlie  vapor- 
laden  air.  A  teaspoonful  of  compound  tincture  of  benzoin 
may  be  added  to  the  water.  The  child  should  not  be  left 
alone,  for  such  an  improvised  tent  is  easily  disarranged  and 
may  take  fire  from  the  alcohol  lamp. 


Fig.  143. — Croup  tent  improvised  by  the  use  of  two  sheets  and  four  broom- 
sticks lashed  to  the  corners  of  a  child's  cot.  The  steam  kettle  is  shown  at 
the  right-hand  corner  of  the  picture.     (Hare.) 

If  the  attack  has  already  begun  the  child  should  be  given 
15  drops  of  syrup  of  ipecac  every  fifteen  minutes  until  vom- 
iting occurs.  In  addition  to  the  vapor  mhalations,  warm 
compresses  may  be  applied  to  the  neck  and  chest.  These 
compresses  are  similar  to  those  described  under  Sore  Throat, 
except  that  they  are  wrung  out  of  hot  water. 


24G  ,  COMMON  EMERGENCIES 

DIPHTHERITIC   CROUP. 

This  is  due  to  true  (li})htlieria,  \\ith  uieuihraue  formation 
on  tlie  vocal  cords.  Tlie  symptoms  are  similar  to  those  of 
spasmodic  crou]),  except  for  the  fact  that  the  ins})iratory 
stridor,  or  crow,  is  constant  and  does  not  occur  in  attacks. 
A  child  in  such  a  conchtion  should  recci\'e  antitoxin  and 
other  treatment  for  diphtheria  without  delay. 

COUGH. 

This  may  occur  as  ])art  of  an  infectious  cold  or  it  may  be 
due  to  irritation  caused  by  smoke,  dust,  or  any  of  the  muner- 
ous  forms  of  irritating  gases.  A  severe,  persistent  cough 
may  be  a  symptom  of  bronchitis,  tuberculosis,  or  pneumonia. 

Treatment. — The  irritation  may  be  often  allayed  by  5  or 
10  (h-ops  of  syrup  of  ipecac  in  a  little  water.  A  favorite 
household  remedy  consists  of  equal  parts  of  glycerin,  ^^'hisky, 
and  rock  candy  (or  sugar),  given  in  teaspoonful  doses  every 
hoiu*.  Steam  inhalations  with  compound  tincture  of  benzoin, 
as  outlined  above  for  laryngitis,  or  a  cold  compress  applied 
to  the  neck,  may  be  tried.  When  the  cough  is  persistent, 
or  when  it  is  associated  with  fe^'er,  the  advice  of  a  physician 
should  be  obtained. 

SHORTNESS    OF   BREATH. 

After  exercise  a  certain  degree  of  shortness  of  breath  is 
normal,  l)ut  when  the  sjTuptom  persists  for  a  half-hour  or 
longer,  or  is  out  of  j^roportion  to  the  degree  of  exertion,  it 
may  indicate  heart  troul)lc. 

Treatment. — The  treatment  consists  of  rest  and  stimula- 
tion. Taticnts  with  weak  hearts  are  usually  very  uncom- 
fortable when  obliged  to  lie  flat  in  bed,  consequently  they 
should  be  allowed  to  sit  up  in  a  chair  in  the  position  which 
they  find  the  most  comfortable.  Stimulation  with  aromatic 
spirits  of  ammonia  or  strong  cofl'ec  should  be  given  and  a 
physician  secured  at  once. 


NAUSEA  AND  VOMITING  247 

INDIGESTION. 

By  indigestion  we  usually  mean  a  sense  of  fulness  and 
indefinite  abdominal  distress  after  eating.  This  may  occur 
after  a  large  meal  or  after  eating  only  a  small  amount  of 
some  particularly  indigestible  food.  Some  persons  cannot 
eat  a  single  mouthful  of  raw  apple  without  suffering  from 
indigestion. 

Indigestion  is  only  a  symptom  and  may  indicate  gastric 
ulcer,  chronic  gastritis,  hyperacidity,  or  any  one  of  several 
other  conditions. 

Treatment. — The  distress  may  sometimes  be  relieved  by 
a  cup  of  hot  water,  a  glassful  of  Vichy,  a  little  bicarbonate 
of  soda  dissolved  in  water,  or  by  several  soda-mint  tablets. 

Drugs  which  are  warming  and  slightly  stimulating  fre- 
quently relieve  the  gastric  distress.  The  most  familiar  of 
these  drugs  are  essence  of  peppermint,  ginger  tea,  brandy 
or  whisky,  or  any  other  similar  form  of  medication.  Rhu- 
barb and  soda  mixture,  which  can  be  procured  in  any  drug 
store,  may  be  given  in  teaspoonful  doses  every  half-hour  for 
several  doses. 

If  the  distress  is  severe  the  patient  may  be  encouraged  to 
vomit.  The  best  way  to  accomplish  this  is  to  give  a  glass 
or  two  of  lukewarm  water  and  then  to  cause  vomiting  by 
tickling  the  back  of  the  throat  with  the  index  finger. 

NAUSEA   AND   VOMITING. 

This  condition  may  result  from  overeating,  from  the  eat- 
ing of  indigestible  food,  or  from  the  taking  of  some  form  of 
poison  (often  ptomains) .  In  addition,  it  occurs  at  the  begin- 
ning of  many  infectious  diseases  (especially  in  children)  and 
is  often  associated  with  diseases  of  the  stomach  and 
intestines. 

Treatment. — For  the  cases  which  result  from  simple  causes, 
such  as  overloading  of  the  stomach,  it  is  best  to  wash  out 
the  stomach  as  outlined  above.  If  the  vomiting  persists 
after  the  stomach  is  emptied,  it  is  apparently  due  to  some 
cause,  or  causes,  more  deeply  seated. 


24S    .  co^r^mx  emergencies 

In  the  absence  of  a  physician,  efforts  should  be  directed 
toward  those  remedies  v  hich  tend  to  lessen  nausea.  In 
some  cases  it  will  cease  if  absolutely  uothiuf:;  is  gi\eii  by 
mouth  for  several  hours.  In  other  cases,  teasi)oonful  doses 
of  carbonated  water  or  champagne,  given  at  hfteen-minute 
intervals,  will  diminish  the  nausea  and  lessen  the  vomiting. 
In  still  other  cases  a  sodn-mint  tablet  or  a  little  baking  soda 
dissolved  in  water  will  relieve  the  nausea  without  other 
treatment. 

A  hot-water  bottle  or  a  mustard  plaster  j)lace(l  over  the 
pit  of  the  stomach  is  an  additional  measure  \\  hich  may  prove 
efficacious. 

COLIC. 

This  is  the  name  given  to  abdominal  cramps.  The  cramps 
may  occur  as  a  result  of  intestinal  irritation  by  indigestible 
foods  or  ])oisons,  or  it  may  occur  as  a  result  of  disease,  such 
as  appendicitis,  gall-stones,  or  strangulated  hernia. 

The  colic  of  appendicitis  begins  in  the  center  of  the  abdo- 
men like  any  other  colic,  but  after  a  few  hours  becomes 
localized  in  the  lower  part  of  the  right  side  of  the  abdomen. 
In  ordinary  "green-apple"  colic  the  pain  is  more  general  in 
character,  being  most  se\'ere  in  the  region  of  the  na\el. 

Treatment. — The  treatment  is  similar  to  the  treatment  of 
indigestion.  If  it  is  reasonably  certain  that  the  cramps  are 
due  to  improper  food  or  poisons,  a  cathartic  should  be  gi\'en 
at  once.  Castor  oil  or  salts,  because  they  work  quickly,  are 
])referable  to  slower  acting  cathartics.  In  many  cases  a 
soapsuds  enema  which  empties  the  lower  bowel  will  relieve 
the  cramps.  In  addition,  a  hot-water  bag,  or  other  form  of 
heat,  may  be  applied  to  the  abdomen.  If  there  is  fever  or 
shock  the  condition  is  m<^re  serious  in  character  and  requires 
the  attention  of  a  physician  at  once. 

APPENDICITIS. 

The  sATTiptoms  are  very  similar  to  those  just  given,  but 
the  typical  symptom  of  appendicitis  is  tenderness  on  deep 
pressure  in  the  lower  half  of  the  right  side  of  the  abdomen. 
This   local   tenderness   sometimes   occurs   alone,   but    it   is 


DIARRHEA  249 

almost  always  associated  with  fever,  and  often  with  nausea 
and  vomiting  and  generalized  abdominal  colic. 

Treatment. — If  appendicitis  is  suspected  the  patient  should 
be  kept  flat  in  bed,  nothing  but  water  being  given  by  mouth, 
and  an  ice-bag  being  placed  over  the  area  of  tenderness. 
Cathartics  are  never  prescribed,  but  there  is  no  harm  in 
giving  an  enema,  which  may  relieve  the  colic.  If  there  are 
any  symptoms  which  suggest  appendicitis  the  early  services 
of  a  physician  are  required. 

DIARRHEA. 

We  have  already  seen  that  diarrhea  is  associated  with 
ptomain  poisoning,  but  it  may  also  be  caused  by  other  forms 
of  poisoning  or  by  the  ingestion  of  indigestible  food,  such  as 
green  apples. 

It  may  be  looked  upon  as  an  attempt  on  the  part  of  the 
intestine  to  rid  itself  of  substances  which  are  injurious. 
Consequently,  we  should  always  start  any  plan  of  treatment 
by  using  something  which  will  thoroughly  cleanse  the 
bowels. 

Treatment. — Castor  oil  is  the  best  remedy  for  diarrhea. 
In  addition  to  causing  an  active  and  early  movement  of  the 
bowels  the  oil  is  soothing  to  the  irritated  intestine.  If  castor 
oil  cannot  be  taken  a  Seidlitz  powder  or  dose  of  Epsom  salts 
may  be  given.  If  these  are  vomited,  as  sometimes  happens, 
calomel  may  be  given  in  y^-grain  doses,  every  fifteen  min- 
utes for  ten  doses.  The  calomel  should  be  followed  six  to 
twelve  hours  later  by  a  Seidlitz  powder  or  a  dose  of  Epsom 
salts. 

After  the  cathartic  has  acted,  small  doses  of  brandy,  or 
bismuth^  may  be  given.  Paregoric  in  10-drop  doses  every 
hour  for  five  or  six  doses  may  be  given  to  an  adult,  but 
should  never  be  given  to  young  children.  Never  attempt 
to  check  diarrhea  until  the  intestines  have  been  cleaned  out 
by  suitable  catharsis. 

After  an  attack  of  diarrhea  the  diet  should  be  absolutely 

'  Bismuth  is  given  in  the  form  of  bismuth  subnitrate,  10  grains  in  a  little 
water  evei-y  two  or  three  hours. 


250 


COMMON  EMERGENCIES 


non-irritating.  Broths,  tea,  coffee,  and  fruit  juices  contain 
no  irritating  residue,  and  may  be  given  freely.  After  the 
diarrhea  has  ceased,  boiled  milk  can  be  given,  and  later 
bread,  cooked  cereal,  custard,  and  other  sim])le  foods. 

The  couunercial  diarrhea  and  "cholera"  cures  usually 
contain  ophun,  and  are  seldom  free  from  danger.  They 
should  uever  be  given  to  children. 

HEMORRHOIDS. 

This  condition,  conunouly  called  "piles,"  may  require 
emergency  treatment  either  l^ecause  of  se\'ere  pain  or 
because  of  hemorrhagic 


Fig.  144. — Showing  protruding  internal  piles.     (Lynch.) 


Piles  are  small  dilated  veins  in  the  region  of  the  anus. 
They  may  be  internal,  that  is,  inside  the  bowel,  or  external, 
near  the  margin  of  the  anus.  They  may  become  inflamed 
and  very  painful,  or  they  may  be  ruptured,  causing  more  or 
less  profuse  hemorrhage.  When  not  inflamed  they  cause 
little  or  no  jiain. 


PAINFUL  JOINTS  251 

Treatment. — Internal  piles  should  be  at  once  reduced. 
That  is,  they  should  be  pushed  back  into  the  bowel  with 
the  finger  previously  well  greased  with  vaselin. 

The  pain  from  either  internal  or  external  piles  may  be 
relieved  by  an  enema  or  by  cold  compresses.  During  the 
period  of  severe  pain  it  is  well  to  give  a  small  enema  before 
the  bowels  move  so  that  they  will  move  easily  and  there 
will  be  no  injury  during  the  movement. 

Although  hemorrhage  from  piles  is  common,  serious 
hemorrhage  is  extremely  rare.  If  there  has  been  profuse 
hemorrhage  the  patient  should  rest  quietly  in  bed  and,  if 
necessary,  a  few  ounces  of  cold  water  may  be  injected  into 
the  rectum.  If  an  external  pile  is  bleeding  a  dry  compress 
may  be  applied  directly  to  the  bleeding-point. 

If  piles  are  present,  hemorrhage  and  pain  may  be  pre- 
vented by  careful  attention  to  the  following  three  rules: 

1.  Never  strain  in  attempting  to  make  the  bowels  move. 

2.  If  the  hemorrhoids  are  forced  down  through  the  anus 
always  press  them  back  at  once. 

3.  Never  allow  the  bowels  to  become  constipated. 

■  PAINFUL   JOINTS. 

The  joints  may  be  painful  from  sprains,  from  injury,  or 
from  disease.  Acute,  or  chronic,  infectious  arthritis  is  the 
name  given  to  an  inflammation  of  the  joints  which  results 
from  the  entrance  of  infectious  material  into  the  joint.  The 
poison  may  be  derived  from  a  focus  in  other  parts  of  the  body. 
Purulent  inflammation  of  the  tonsils  or  teeth  may  serve  as  a 
point  of  entrance  for  infection  of  the  joints.  Acute  articular 
rheumatism  is  one  of  the  commonest  types  of  acute  infection 
of  the  joint. 

Treatment. — ^The  treatment  depends  largely  upon  the 
cause.  For  the  infectious  types  medical  treatment  is  required. 
For  the  traumatic  cases  and  for  mild  cases  of  ill-defined 
origin  the  pain  may  be  temporarily  relieved,  by  the  use  of 
heat,  either  in  the  form  of  dry  heat  or  by  the  application  of 
hot  compresses,  combined  with  rest  of  the  affected  joint. 
If  an  ointment  of  oil  of  wintergreen  can  be  secured  it  may  be 
applied  over  the  painful  area  and  the  joint  covered  with  a 


252      .  COMMON  EMERGEXCIES 

thick  liiycr  of  cotton,  which  is  thi-n  firmly  bandap;od  in  place. 
Ill  transj)ortation  of  ])aticnts  with  ])ainfiil  or  inflamed 
joints  a  suitable  splint  is  ai)plic(l  so  that  the  weight  of  the 
limh  is  su])i)ortc(l. 

PAINFUL   MUSCLES. 

One  of  the  commonest  causes  of  ])ain  referred  to  the 
muscles  is  "muscle  strain,"  which  has  already  been  dis- 
cussed. Ill  addition,  unusual  muscular  exertion  may  result 
in  cither  general  or  local  "soreness."  Neuritis  may  cause 
a  severe  pain  which  the  patient  often  refers  to  the  definite 
group  of  muscles. 

Treatment. — Massage  either  with  or  without  the  use  of  a 
liniment  will  often  relieve  the  pain  in  the  muscles.  Athletes 
make  use  of  this  in  the  rubbing  which  they  receive  before 
and  after  any  unusual  exercise.  The  form  of  liniment  is  not 
important.  S])irits  of  camphor,  chloroform  liniment,  cap- 
sicum ointment,  and  many  others  may  be  used.  The  main 
requirement  is  to  secure  an  increased  circulation  of  the  j^art, 
^\'ith  a  certain  amount  of  counter-irritation. 

When  the  pain  is  very  severe,  local  heat,  preferably  dry 
heat,  may  be  used.  I  require  patients  suffering  from  muscular 
pains  to  sit  in  front  of  an  open  fire  and  toast  the  i)ainful 
muscles  for  thirty  minutes  or  more  twice  daily.  Heat  in 
the  form  of  hot-water  bags,  or  electric  pads,  or  any  other 
availal)le  form  of  heat  will  usually  give  relief. 

WARTS    AND   MOLES. 

AYarts,  moles,  and  other  small  tumors  should  be  removed 
surgically.  While  it  is  sometimes  possible  to  remove  these 
tumors  by  the  use  of  caustics,  such  measures  may  cause  the 
growth  to  become  cancerous.  For  this  reason  it  is  never 
advisable  to  attempt  their  removal  except  under  the  ach'ice 
of  a  physician. 

IVY   POISONING. 

There  are  several  varieties  of  plants  \\hich  may  cause  skin- 
poisoning.  They  belong  to  the  oak  or  sumac  family,  and 
are  spoken  of  as  poison  ivy  or  poison  oak. 


IVY  POISONING 


253 


From  the  stand-point  of  treatment  the  differentiation  of 
the  several  varieties  is  not  important,  for  the  skin  symptoms 
are  practically  the  same. 

These  plants  are  extremely  poisonous,  so  that  when 
touched  they  cause  severe  irritation  of  the  skin.    A  peculiar 


Fig.  145. — Rhus  toxicodendron:    leaf  half  natural  size.     This  is  the 
common  form  of  poison  i\'y.     (Culbreth.) 


circumstance,  however,  is  that  some  persons  are  apparently 
immune  to  the  poison,  being  able  to  handle  the  plants  with 
impunity.  On  the  other  hand,  some  persons  are  especially 
susceptible,  even  the  slightest  touch  resulting  in  a  severe 
reaction. 

The  poison  may  be  carried  from  one  part  of  the  body  to 


254    .  COMMON  EMERGENCIES 

another.  That  is,  if  it  is  on  the  liands  it  may  be  carried 
to  the  face  or  any  other  }iart  of  the  body.  ^  ery  rarely 
one  person  may  transmit  it  by  direct  toucli  to  tlie  skin 
of  another. 

It  is  important  to  recognize  and  to  a^■oid  poison  ivy 
w'hene^'e^  in  the  woods.  Do  not  conchide  that  because  you 
ha\'e  touched  the  ])lant  once  without  injury  you  arc  immune. 

The  disease  becomes  e\'ident  l)y  scattered  areas  of  redness, 
usually  beginning;  on  the  hands  and  face,  but  soon  being 
spread  to  other  parts  by  scratching.  The  reddened  areas 
become  acutely  inflamed  and  swollen,  numerous  small 
blisters  form,  and  there  is  intense  itching.  This  condition 
usually  begins  about  two  or  three  days  after  exposure, 
increases  for  two  or  three  days,  and  then  gradually  subsides. 


Fig.  146. — Showing  the  formation  of  Ijlehs  on  the  wrist,  the  result  of  ivy 
poisoning.     (Ornisl).\-.) 

Treatment.— The  patient  usually  requires  treatment  to 
relieve  the  itching.  Bicarbonate  of  soda  solution  (2  per  cent.), 
carbolized  ^'aselin  (5  per  cent.),  and  lime-water  may  all  be 
tried.  In  the  use  of  soda  solution  or  lime-water,  cloths  are 
wet  and  placed  over  the  inflamed  area,  being  kept  constantly 
wet  with  the  solution  used.  Carbolized  vaselin  is  smeared 
upon  the  eruption  once  or  twice  daily. 

During  the  later  stages  zinc  oxide  ointment  may  be  spread 
over  the  entire  surface. 

Recovery  is  usually  complete  in  about  ten  days.  In  a  few 
cases  the  blisters  may  become  infected,  in  which  case  a  wet 
boric  acid  dressing  should  be  applied. 


CHAPTER  XIII. 
TRANSPORTATION. 

In  the  treatment  of  an  injured  person  it  is  usually  neces- 
sary to  remove  him  from  the  spot  where  the  injury  was 
received  to  a  location  more  suitable  for  treatment.  In  cities 
this  is  usually  accomplished  by  the  public  ambulances,  but 
in  the  country  this  duty  falls  on  the  man  trained  in  first 
aid. 

As  the  conveniences  of  civilization  are  left  farther  and 
farther  behind  a  clear  understanding  of  the  best  methods 
of  transportation  becomes  of  greater  and  greater  importance. 
In  camp  life  and  on  the  battlefield  the  problem  of  the  care 
of  the  sick  and  wounded  is  largely  one  of  transportation. 
There  are  so  few  conveniences  for  the  care  of  the  injured 
on  the  battle  ground  and  deep  in  the  forests  that  all  except 
the  severely  injured  must  be  carried  to  a  point  where  con- 
veniences for  treatment  are  obtainable. 

And  it  is  more  than  a  matter  of  simple  transportation. 
The  carrying  must  be  done  intelligently,  with  due  regard 
to  the  injuries  of  the  patient  and  the  distance  to  be  traversed. 
A  broken  bone  may  be  thrust  tlirough  the  skin,  resulting 
in  a  compound  fracture,  or  bleeding  from  a  wound  may  be 
increased  by  unskilled  handling  of  the  injured  person.  Trans- 
portation which  causes  an  increased  amount  of  pain,  and 
which  wastes  the  patient's  strength,  tends,  as  we  have  seen, 
to  increase  the  amount  of  shock. 

Before  attempting  any  sort  of  transportation  a  careful 
examination  should  be  made  to  determine  the  nature  of  the 
injury.  First  aid  should  be  given  and  the  necessary  splints 
and  dressings  applied.  If  the  bleeding  from  the  wound  is 
profuse  it  is  much  wiser  not  to  attempt  transportation, 
except  for  very  short  distances,  until  the  hemorrhage  has 
practically  entirely  ceased. 


25()  THA  XSlVh'TA  TJON 

The  character  of  the  transportation  (lei)en(ls  hirgely  upon 
the  nature  of  the  coniphiint  and  ui)on  tlie  means  of  trans- 
portation at  hand.  For  long  distances,  wheel  transporta- 
tion, wagon,  or  automobile,  is  nnich  preferred.  For  short 
distances  trans]5ortation  by  stretcher  or  litter,  when  avail- 
able, is  the  most  desirai)le  method. 


LITTER   TRANSPORTATION. 

A  litter,  or  stretcher,  is  commonly  made  of  can\as  stretched 
between  two  poles,  the  ends  of  the  i)oles  serving  as  handles. 
There  are  difi'erent  varieties  of  litters  in  use,  each  of  which 
may  have  some  particular  advantages  for  the  special  use 
for  which  it  is  intended.  For  field  work  the  United  States 
Army  litter  is  one  of  the  best. 

The  regulation  hand  litter  consists  of  a  canvas  bed  6  feet 
long  and  22  inches  wide,  made  fast  to  two  poles  7^  feet  long, 
and  stretched  by  two  jointed  braces.  The  ends  of  the  poles 
form  the  handles,  9  inches  long,  by  which  the  litter  is  car- 
ried. The  fixed  iron  legs  are  stirru})-shaped,  4  inches  high 
and  If  inches  wide.  On  the  left  front  and  rear  handles  a 
half-round  iron  ring  is  fixed,  4^  inches  from  the  end;  between 
this  and  the  canvas  plays  a  movable  ring  of  the  sling. 

One  pair  of  slings  is  permanently  attached  to  each  litter. 
They  are  made  of  khaki-colored  webl)ing,  2^  inches  wide, 
with  a  leather  lined  loop  at  each  end  and  a  slide  to  regulate 
the  length.  One  loop  of  the  sling  passes  through  the  metal 
swi\'el,  itself  attached  to  the  mo\'able  ring  of  the  handle.^ 

The  advantages  of  this  litter  are  that  it  can  be  folded  into 
small  space  when  not  in  use;  it  is  held  slightly  raised  from  the 
ground  t>y  the  fixed  iron  legs  so  that  it  serves  as  a  temporary 
bed;  and,  because  of  the  carrying  straps,  it  is  well  adapted 
for  carrying  patients  long  distances. 

Its  chief  disadvantage  is  that  it  is  unnecessarily  heavy  for 
the  ordinary  emergency  work.  The  methods  of  impro^•ising 
stretchers  will  be  referred  to  later. 

1  Drill  Regulations  and  Service  Manual  for  Sanitary  Troops,  United  States 
Army,  1014. 


LITTER   TRANHPOIiTATION  257 

Litter  Drills. — It  is  not  al)S()lutcly  necessary  that  a  thor- 
ough knowledge  of  first  aid  should  include  a  knowledge  of 
litter  drill,  but  in  all  field  work,  in  factories,  in  schools,  and 
in  such  organizations  as  the  Boy  Scouts,  a  knowledge  of  a 
definite  drill  will  enable  a  given  group  of  men  to  accomplish 
much  better  results  in  less  time  than  it  is  possible  without 
some  form  of  drill. 

The  following  drill  is  modified  from  the  Regulations  of  the 
Sanitary  Troops,  United  States  Army: 

In  the  military  service,  to  secure  uniformity  and  precision 
in  the  execution  of  all  movements,  commands  are  invariably 
given  in  two  parts — the  first  called  the  preparatory  command 
and  the  second  the  command  of  execution.  Except  in  very 
few  instances  no  movement  is  made  at  the  "preparatory 
command"  but  all  "prepare  themselves"  at  this  command 
to  complete  the  movement  in  unison  at  the  "command  of 
execution." 

The  litter  squad  consists  of  two  men — No.  2,  counting  from 
the  right,  is  the  squad  leader  unless  a  special  squad  leader 
is  designated.  In  all  cases,  even  with  a  special  squad  leader 
or  captain,  No.  2  or  the  rear  litter  bearer,  should  watch  the 
movements  of  the  front  bearer  and  time  his  own.  by  them 
so  as  to  insure  ease  and  steadiness  of  action.  The  bearers 
should  keep  the  litter  horizontal,  notwithstanding  any 
unevenness  of  the  ground.  i 

As  nearly  as  possible,  complementary  movements  are 
paired.     The  commands  of  execution  are  given  in  "sal\ll 

CAPITALS." 

The  squads  having  "Fallen  In"  and  their  position  numbers 
designated  the  command  is  given: 

Procure  litter.  March.  At  the  command  march  the 
No.  2  or  2's^  proceed  to  the  litter  or  litters  and  each  man 
puts  one  on  his  shoulder  and  returns  to  his  position  in  line. 

1  When  more  than  one  squad  is  assembled  it  is  customary  to  execute 
this  movement  as  follows:  Commands:  Procure  litter.  Right  (left)  face. 
MARCH.  At  litter,  each  No.  2  steps  one  pace  to  the  front;  at  face  they  face 
as  required,  and  at  MARCH  proceed  in  column  of  files  by  the  nearest  route 
to  the  litters.  They  each  take  one,  place  it  on  right  shoulder  at  an  angle  of 
45  degrees,  canvas  down,  and  return  in  reverse  order  and  resume  places  in 
rank. 

17 


258  77»M  X  SPORT  A  TION 

Being  in  line,  litters  at  the  shoulder: 

Carry.     Litter. 

At  Litter,  each  No.  2  brings  his  litter  to  the  vertical 
position,  drops  the  upper  handles  forward  and  downward 
until  the  litter  is  in  a  horizontal  position,  canvas  up,  and 
grasps  the  outside  handle  with  his  right  hand;  meanwhile 
No.  1  steps  directly  to  the  front  until  he  is  opposite  the 
front  handles  when  he  grasps  his  outside  handle  with  his 
left  hand. 

Being  at  the  carry: 

Shoulder.    Litter. 

At  Litter,  No.  2  advances  and  plants  the  left  foot  one 
pace  forward,  reaches  forward  with  the  left  hand  and  grasps 
the  litter  near  its  center,  grasps  the  right  stirru]")  A\'ith  the 
right  hand,  and  brings  the  litter  to  the  vertical  position  and 
then  to  the  shoulder,  at  the  same  time  replacing  the  left 
foot  by  the  right;  meanwhile  No.  1  steps  backward  and 
aligns  himself  on  No.  2. 

Being  at  the  carry: 

Ground.     Litter. 

At  Litter,  the  bearers  stoop  and  lower  the  litter  to  the 
ground,  canvas  up,  and  stand  erect,  facing  the  front. 

Being  at  the  ground: 

Carry.     Litter. 

At  Litter,  the  bearers  stoop,  grasp  the  handles  and  raise 
the  litter  from  the  ground  to  the  carry. 

The  above  movements  are  only  executed  with  the  closed 
litter. 

Being  at  the  carry,  litter  closed. 

Open.    Litter. 

At  Litter,  both  bearers  face  the  litter  and  slip  the  free 
loop  of  each  sling  upon  the  ring  handle,  the  bight  embracing 
the  opposite  handle;  they  then  grasp  the  left  handles  with 
their  left  hands  and  drop  the  other  handles,  the  litter  being 
thus  suspended  by  the  left  pole,  canvas  to  the  right.  They 
then  fully  extend  the  braces,  lower  the  litter  to  the  ground, 
canvas  up,  and  stand  between  the  handles,  facing  the  front. 

The  litter  being  open  and  lowered: 

Close.    Litter. 


LITTER   TRANHI'OIITATION  259 

At  LiTTEE,  Nos.  1  and  2,  respectively,  step  outside  the 
right  front  and  left  rear  handles,  and  face  inward;  they 
stoop  and  with  their  hands  raise  the  litter  by  the  handle  of  tlie 
left  pole;  they  then  fold  the  braces,  and  bringing  the  lower 
pole  against  the  upper,  face  to  the  front  and  support  the 
litter  at  the  carry. 

To  bring  the  squad  into  line,  the  litter  being  at  the  ground 
or  the  open,  with  the  men  at  litter  posts: 

Form.     Rank. 

At  Rank,  No.  1  advances  one  pace  and  No.  2  aligns  him- 
self on  No.  1.  Original  positions  at  the  litter  are  resumed  at 
the  command  "litter — posts,"  all  executing  an  about  face, 
proceeding  to  their  posts  at  the  litter,  and  facing  to  the 
front  together. 

This  movement  permits  the  marching  of  the  squad,  with- 
out litter,  to  any  desired  point. 

Posts  at  the  litter  may  at  any  time  be  recovered  by  the 
commands : 

Litter.    Posts. 

If  at  the  ground  the  numbers  take  posts,  No.  1  on  the 
right  of  the  front  handles.  No.  2  on  the  left  of  the  rear 
handles  and  close  to  them,  facing  the  front.  If  at  the  open, 
Nos.  1  and  2  take  posts  between  the  front  and  rear  handles, 
'respectively,  facing  the  front. 

The  foot,  or  front,  of  a  grounded  or  opened  (unloaded) 
litter  is  the  end  farthest  from  the  advancing  squad,  unless 
otherwise  designated.  The  foot  of  a  loaded  litter  is  always 
the  end  corresponding  to  the  feet  of  the  patient. 

In  case  a  permanently  (fixed)  open  litter  only  is  available 
the  closed  litter  movements  must  be  dispensed  with.  The 
commands  for  the  squad  with  an  open  litter  are  alwaj's  the 
same,  whether  the  litter  is  empty  or  loaded;  in  other  words, 
always  treat  the  open  litter  as  if  it  were  loaded. 

As  a  rule  the  patient  should  be  carried  on  the  litter  feet 
foremost,  but  in  going  uphill  his  head  should  be  in  front. 
In  case  of  fracture  of  the  lower  extremities  he  is  carried  uphill 
feet  foremost  to  prevent  the  weight  of  the  body  from  pressing 
on  the  injured  part. 

To  maneuver  properly  with  the  open  litter,  litter  intervals 


260_  TEA  XSPORTA  TION 

must  he  taktMi.  Of  course,  it  is  ()b\'ious  that  tliis  is  necessary 
only  Nvhen  more  than  one  htter  stjuad  is  heinj;'  (h-illed.  The 
mo\ement  is  as  follows: 

Beinjr  in  line,  litters  at  the  shoulder: 

Take  litter  interval.    To  the  right  (left).    March. 

Detachment.     Halt. 

At  the  command  Maiuu  Nos.  2  bring  their  litters  to  the 
vertical  position,  all  face  to  the  right  (left),  and  the  leading 
squad  steps  ofi",  Xos.  1  and  2  of  each  scpiad  i)reserving  facing 
distance  with  relation  to  each  other.  When  the  leading 
squad  has  advanced  three  paces  the  squad  next  in  order  steps 
oli"  following  it  in  column,  and  so  on,  until  all  the  squads 
are  marching  in  the  indicated  direction,  three  paces  apart. 

At  Halt,  all  halt  and  face  to  the  original  front,  the  litters 
being  returned  to  the  shoulder  ])osition. 

This  formation  is  designated  "line  of  litters"  regardless  of 
the  position  of  the  litter. 

To  asseiuble,  being  in  line  of  litters,  at  the  shoulder. 

Assemble  to  the  right  (left).     March. 

At  ]\Iarcii,  the  squad  on  the  flank  indicated  stands  fast 
in  position.  The  other  squads  face  to  the  right  (left),  close 
in  as  commanded  and  face  to  the  front. 

Being  at  the  open : 

Prepare  to  lift.     Lift. 

At  the  first  command  the  bearers  without  facing  about, 
stoop,  slip  the  slings  off  the  handles  and  place  them  over 
their  shoulders;  they  then  replace  the  free  looj)  on  its  handle, 
adjust  tjie  length  of  the  slings  if  necessary,  and  firmly  grasp 
the  handles  of  the  litter;  at  Lift  they  slowly  rise  erect. 

Being  at  the  lift: 

Lower.    Litter. 

At  Litter,  the  bearers  slowly  lower  the  litter  to  the  ground. 
Each  number  then  seizes  the  free  loop  and  bight  of  his  sling, 
removes  the  sling  from  his  shoulders,  and  places  the  loop 
on  the  ring  handle,  the  bight  embracing  the  opposite  handle. 

Being  at  the  lift: 

Forward.     March. 

The  bearers  step  off",  Xo.  1  with  the  left  and  No.  2  with 
the  rigid  foot,  taking  short  sliding  steps  of  about  20  inches, 


LITTER   TRANSPORTATION  201 

to  avoid  jolting  and  to  secure  a  uniform  motion  to  the  litter. 
The  cadence  is  at  about  100  steps  to  the  miiuite. 

The  marching  movements  with  the  htter  are  very  similar 
to  those  of  the  squad  in  the  Army  Manuul  except  that  com- 
mand "litter"  replaces  that  of  "fours"  and  ordinarily  a 
litter  squad  turns  or  "wheels"  on  its  own  ground. 

The  Loaded  Litter. — In  moving  the  patient  either  with  or 
without  the  litter,  every  movement  should  be  made  delib- 
erately and  as  gently  as  possible,  having  special  care  not  to 
jar  the  injured  part.  The  command  steady  will  be  used  to 
prevent  undue  haste  or  other  irregular  movements.  The 
loaded  litter  should  never  be  lifted  or  lowered  without 
orders.    The  handles  of  the  litter  should  be  held  in  the  hands 


FiG.  147. — Method  of  lifting  a  patient  on  or  off  the  litter. 

at  arm's  length  and  supported  by  the  slings.  Only  under 
most  exceptional  conditions  should  the  handles  be  supported 
on  the  shoulders. 

Under  exceptional  circumstances,  as  in  ascending  or 
descending  stairs,  when  the  patient  is  very  heavy,  the  ground 
difficult,  or  an  obstacle  over  3  feet  high  has  to  be  surmounted, 
it  may  be  necessary  to  use  additional  bearers.  In  this  case 
the  additional  man  or  squad  is  aligned  on  the  left,  and,  when 
necessary,  assigned  to  any  position  designated  by  the  squad 
leader. 

To  load  the  litter:  the  litter  being  at  the  open:  two  ways 
designated : 

1.  Right  (left)  side.     Posts. 

At  the  command  Posts  the  bearers  go  to  the  right  (left) 


202 


T  RAX  SPORT  AT  lOX 


side  of  patient  and  take  ])()sitions,  No.  1  at  ri<j;lit  (left)  thigh 
and  Xo.  2  at  right  (left)  shoulder,  facing  the  i)atient. 

Prepare  to  lift.     Lift. 

At  the  first  command  the  hearers  kneel  on  the  knee  near- 
est the  ])atient's  feet,  No.  1  i)asses  one  arm  under  the 
patient's  hips  and  the  other  beneath  the  knees;  No.  2  passes 
one  arm  under  the  shoulders  to  the  farther  armpit,  and  the 
other  arm  beneath  the  small  of  the  back. 


Fig.  148. — Carrying  a  litter  patient  in  the  recumbent  position. 


At  Lift  they  lift  together,  slowly  and  carefully,  raising 
the  patient  upon  their  knees,  then  readjusting  their  hold, 
rise  to  their  feet  and  carry  the  patient  by  the  shortest  route 
to  the  side  of  the  litter,  where  the  squad  is  halted. 

Lower.     P.\tient. 

At  Patient,  the  bearers  kneel  and  ])lace  the  patient  on 
their  knees;  they  stoop  forward  and  lower  him   gently  on 


LITTER   TRANSPORTATION  263 

the  litter;  they  then  rise  and  at  once  resume  tlieir  positions 
at  litter  posts,  without  command. 

Should  it  be  necessary  in  emergencies  to  use  three  bearers, 
this  may  be  done  with  similar  commands,  by  having  the 
third  bearer  placed  at  the  patient  in  such  a  way  that  he  may 
support  the  knees  and  legs. 

2.  Hips.    Posts. 

At  Posts,  No.  1  proceeds  to  the  patient's  right  hip  and 
No.  2  to  the  left  hip,  facing  the  patient. 

Prepare  to  lift.    Lift. 

At  the  first  command  the  bearers  kneel  on  the  knee  near- 
est the  patient's  feet;  they  then  raise  him  to  a  sitting  posi- 
tion and  pass  each  one  hand  and  arm  around  his  back, 
while  the  other  hands  are  passed  under  the  thighs,  grasping 
hands.  The  patient,  if  able,  clasps  his  arms  around  the 
bearers'  necks.  At  Lift,  they  lift  the  patient  both  rising 
together  and  carry  him  to  the  center  of  the  side  of  the  litter 
where  the  squad  is  halted. 

Lower.    Patient. 

At  Patient  the  bearers  stoop  and  lower  the  patient  upon 
the  litter  to  a  sitting  position,  the  patient  releasing  his 
hold  around  the  bearers'  necks.  No.  2  then  passes  his  left 
hand  across  the  patient's  chest  to  the  opposite  armpit  and 
grasps  the  patient.  No.  1  releases  his  hold  at  the  right  of 
the  patient,  steps  astride  of  the  patient's  lower  extremities 
and  grasps  the  patient's  right  and  left  thighs  just  above  the 
knees  with  his  left  and  right  hands,  respectively.  Both 
bearers  then  turn  and  lower  the  patient  upon  the  litter, 
head  toward  No.  2  and  take  their  positions  at  litter  posts 
without  commands. 

To  unload,  posts  are  taken  and  the  patient  lifted  in  the 
same  manner  and  by  the  same  commands.  At  Hips — Posts, 
the  bearers  take  their  posts  at  the  sides  of  the  litter  and  at 
prepare  to  lift  they  lift  the  patient  to  a  sitting  position  on 
the  side  of  the  litter  by  reversing  the  movements  heretofore 
described  and  then  take  the  positions  of  prepare  to  lift. 

The  bearers  move  backward  if  at  "side,  Posts"  and  for- 
ward if  at  "hips,  Posts,"  until  clear  of  the  litter,  when  they 
halt  and  lower  the  patient. 


2G4 


T  RAN  SPORT  ATIOX 


The  drill  should  be  made  as  nearly  as  possible  like  aetiial 
first-aid  work.  For  this  i)uri)ose  a  diajiuosis  tag  haviiifj;  been 
attached  to  the  clothing  of  the  "injured  person"  indicating 
the  site  and  character  of  the  injury  to  be  dressed  before 
loading,  the  necessary  first-aid  dressing  should  be  applied 
and  the  "patient"  transported  as  directed. 


Fig.    149. — Method  of  carrying  a  litter  upstairs.     Note  that    the  Htter  is 
carried  in  the  horizontal  position. 

To  Pass  Obstacles. — If  the  ground  is  very  uneven  or  the 
di.stance  far,  the  lu'arer  squads  should  always  consist  of 
three  or  four  men,  preferably  four. 

To  carry  a  loaded  litter  upstairs,  the  patient  should  l)e 
carried  head  first.  The  leading  bearer  (or  bearers)  carries 
his  end  of  the  stretcher  low  and  the  following  bearers  carry 
their  end  high  so  that  the  litter  remains  horizontal.  In 
carrying  flownstairs  the  process  is  reversed  except  that  the 


LITTER   TRA NSPORTA TION 


265 


patient  travels  feet  first.     The  leading  bearers  hold  their 
end  of  the  stretcher  high  while  the  other  end  is  lowered. 

To  cross  a  fence  or  other  low  obstacle  only  two  bearers 
are  necessary.  The  litter  is  placed  on  the  ground  with  the 
head  next  to  the  fence  and.  the  bearers  take  their  places 


Fig.  150. — Method  of  crossing  a  high  obstacle.  When  the  front  end  of 
the  litter  rests  upon  the  fence,  two  bearers  cross  the  fence  and  work  from 
the  other  side. 


at  the  sides  of  the  litter,  lifting  it  until  the  head  of  the  litter 
can  be  rested  on  the  fence.  When  the  front  stirrups  have 
cleared  the  fence  the  bearers  work  back  to  the  foot  and  one 
man  takes  his  place  at  the  foot,  the  other  climbing  across 
the  fence  and  taking  the  head.  The  litter  is  now  lifted  until 
the  foot  rests  on  the  fence  and  the  second  bearer  crosses  the 


2()G  TRA  N  SPORT  A  TION 

fence,  lie  takes  liis  ])la('e  at  the  front  with  the  otlier  bearer 
and  they  work  then-  way  until  they  are  one  t)n  each  side 
near  the  center.  Tlie  Utter  is  now  Hfted  down  and  placed 
on  the  ground  and  two  hearers  take  their  respectixe  places 
at  the  ends  of  the  litter. 

To  cross  a  high  fence  four  bearers  are  necessary.  Ivich 
man  takes  his  place  facing  the  litter,  grasps  a  handle  with 
both  hands  and  raises  it  to  the  top  of  the  fence.  It  is  then 
niovetl  until  the  leading  stirrups  have  cleared  the  fence  and 
allowed  to  rest  there.  The  two  front  bearers  then  cross  the 
fence  and  taking  their  places  advance  the  litter  until  the 
rear  handles  rest  on  the  obstacle.  The  rear  bearers  now  cross 
the  fence  and  take  their  places,  when  the  litter  is  lowered. 
A  litter  may  be  taken  in  or  out  of  a  window  (mi  the  groimd 
floor  in  the  same  manner.  , 

To  place  a  litter  in  an  aml)ulance  two  litter  bearers  take 
their  places  on  the  opposite  sides  of  the  litter  which  is  on  the 
ground  in  the  rear  of  the  ambulance  with  the  patient's  head 
toward  the  amluilance.  At  the  command  "lift"  the  bearers 
lift  the  litter  by  the  sides  and  ad\'ance  toward  the  ambulance 
until  the  front  stirrups  rest  on  the  floor  of  the  ambulance.  The 
litter  may  be  pushed  along  the  floor  of  the  ambulance. 
Always  be  sure  to  make  the  tailboard  fast  after  the  i)atient 
is  placed  in  the  ambulance.  When  going  up  a  steep  hill  it 
is  very  easy  for  the  stretcher  and  the  patient  to  slip  out 
unless  the  tailboard  is  firmly  fixed. 

To  cross  a  narrow  trench  the  stretcher  is  jilaced  with  the 
head  toward  the  trench  and  the  l^earers,  taking  posts  at  the 
sides,  move  it  carefully  to  the  edge  of  the  trench.  They 
then  straddle  the  trench  and,  lifting  the  litter  slightly  from 
the  ground,  advance  it  until  it  bridges  the  trench.  The 
advance  is  continued  until  the  litter  is  entirely  on  the  other 
side. 

In  wide  trenches  or  small  streams  some  sort  of  bridge 
must  be  improvised.  Shallow  streams,  of  course,  may  be 
forded. 

To  Improvise  a  Litter.^There  are  many  ways  of  impro- 
\ising  a  litter.  A  small  light  cot  makes  one  of  the  most 
satisfactory  litters.     Benches,  window  shutters,  doors,  lad- 


UTTER   TRANSPORTATION  267 

ders,  etc.,  all  properly  padded,  may  be  used.  Care  should 
be  taken  that  the  padding  should  be  firmly  attached  to  the 
improvised  litter  or  the  i)atient  will  easily  slip  off. 

A  litter  may  be  made  by  cutting  holes  in  the  bottoms  of 
two  or  three  sacks  and  slipping  two  poles  through  the  bags. 
Cross-pieces  should  be  tied  or  nailed  between  the  ends  of 
the  poles  in  order  to  keep  them  apart.  Canvas,  carpet,  or 
other  heavy  cloth  may  be  tacked  to  two  poles  and  used  in 
the  same  way. 

The  Coat  Litter. — ^The  coat  litter  is  a  great  favorite  in 
first-aid  teaching.  Two  coats  are  removed  and  buttoned 
down  the  front  and  the  sleeves  turned  inside  out.  If  poles 
are  passed  through  the  sleeves  the  coats  form  a  fairly  good 
support.  The  main  disadvantages  are  that  the  buttons  break 
off  and  the  coats  are  apt  to  tear  when  a  patient  is  carried. 

The  Blanket  and  Rifle  Stretcher. — The  blanket  and  rifle 
stretcher,  commonly  used  by  soldiers,  is  an  easily  improvised 
stretcher.  The  blanket  is  spread  out  on  the  ground  and 
an  unloaded  rifle  placed  in  the  center  over  which  the 
blanket  is  folded,  forming  a  rectangle.  In  the  center  of  this 
rectangle  a  second  rifle  is  placed  parallel  to  the  first  and  the 
free  edges  of  the  blanket  folded  over  this  toward  the  first 
rifle.  Poles  may  be  used  instead  of  rifles.  This  form  of 
stretcher  requires  four  men  to  carry  it.  It  is  not  very  firm 
because  the  blankets  easily  slip  loose. 

By  folding  the  blanket  once  from  side  to  side  and  placing 
a  rifle  crossways  at  the  center  so  that  the  butt  and  muzzle 
project  beyond  the  edges,  folding  the  blanket  over  this  and 
placing  the  second  rifle  parallel  to  the  first  and  again  folding 
the  double  blanket,  exactly  the  same  litter  is  formed  as 
described  above,  except  that  it  is  very  short.  Patient  may 
be  carried  in  this  using  it  as  a  seat. 

The  Chair  Litter. — For  emergencies  in  and  about  dwell- 
ings an  ordinary  chair  of  firm  construction  makes  a  most 
satisfactory  litter.  The  patient  is  seated  in  the  chair  which 
is  tilted  backward  so  that  the  patient  lies  in  a  nearly  hori- 
zontal position.  Two  bearers  carry  the  chair,  one  holding 
the  back  of  the  chair  and  the  other,  walking  backward, 
holds  the  chair  by  the  two  front  legs. 


2()S 


TRAXSPORrATiny 


TRANSPORTATION   WITHOUT   LITTER. 

A  single  bearer  may  carry  a  ])atient  in  his  arms  or  on  his 
back. 

To  Lift  a  Helpless  Patient. — The  patient  is  ])hice(l  upon  his 
face  and  tlie  l)earer  stands  astride,  the  back  facin<2;  the  head. 
With  the  hands  under  the  armpits  the  patient  is  lifted  to 


Fig.  1.51. — One  method  Ijy  whicli  a  sinplo  bearer  may  carry  a  patient. 


the  knees;  then  clasping  the  hands  over  the  abdomen  the 
patient  is  lifted  to  his  feet;  the  bearer  then  with  his  left 
liand  seizes  the  patient's  left  wrist  and  draws  the  left  arm 
about  his  own  neck,  holding  the  patient  supi)orted  against 
his  right  side  with  his  right  arm  about  the  waist.  The 
bearer  then  quickly  places  the  left  arm  beneath  the  patient's 


THE  TRAVOfS  269 

thighs  and  lifts  him  up.  If  the  patient  can  help  himself  a 
little  he  can  assist  by  holding  firmly  to  the  bearer's  shoulders 
with  his  left  arm. 

To  Carry  Across  the  Back. — ^l^'he  patient  is  lifted  erect  as 
described  above.  The  bearer  then  seizes  the  right  wrist  of 
the  patient  and  draws  the  arm  over  his  head  to  his  left 
shoulder  where  it  is  held  with  his  left  hand,  then  shifting 
himself  in  front,  he  stoops  and  clasps  the  right  thigh  with 
his  right  arm  passed  between  the  patient's  legs,  reaching 
his  right  hand  upward  to  grasp  the  right  wrist  of  the  patient. 
The  bearer  then  grasps  the  patient's  left  hand  and  holds  it 
to  his  side;  he  then  rises  with  the  weight  of  the  patient 
borne  on  his  shoulders. 

If  the  patient  can  help  himself  he  may  be  carried  astride 
the  back.  He  is  lifted  as  described  above  and  the  bearer 
shifts  in  front,  stoops  and  grasping  one  thigh  under  each 
arm  lifts  the  patient  well  up  upon  his  back,  the  patient  mean- 
while holding  the  bearer  firmly  with  arms  clasped  about 
his  neck. 

Two  bearers  may  carry  an  injured  patient  by  the  use  of 
what  is  known  to  children  as  the  "ladies'  chair."  In  its 
formation,  each  of  the  two  grasps  his  right  wrist  with  his 
left  hand,  back  uppermost  and  then  each  grasps  the  other's 
left  wrist  with  his  right  hand.  The  patient  sits  on  this  and 
places  his  arms  about  the  necks  of  the  bearers  for  support. 

Two  bearers  may  carry  a  patient  as  follows:  One  grasps 
him  beneath  his  armpits  and  the  other  standing  between 
his  legs  grasps  the  thighs  just  above  the  knee.  Both  lift 
together. 

THE    TRAVOIS. 

The  travois  is  a  vehicle  for  the  transportation  of  the  sick 
when  wheel  transportation  is  impracticable.  It  consists  of 
two  long  poles,  the  larger  end  of  each  being  attached  to  the 
sides  of  a  horse  like  shafts,  the  smaller  ends  dragging, 
one  of  which  is  projecting  8  to  10  inches  behind  the  other. 
Behind  the  horse  crossbars  are  set  to  hold  the  poles  apart, 
and  a  canvas  bed  arranged  in  which  the  patient  rests.  An 
attendant  must  walk  behind  to  lift  the  end  of  the  travois 


270  Th'AXsroin'ATiON 

while  traversing::  uneven  jiround  or  fioinj:;  uj)  hill.  As  may 
be  supposed,  this  vehiele  makes  pretty  rough  travelling  for 
an  injured  man. 

If  not  too  badly  injured  a  wounded  man  may  be  earried 
on  liorsebaek,  ])referal)ly  riding  double  with  an  attendant 
who  rides  behind  and  fiu'uishes  necessary  support. 

WHEEL   TRANSPORTATION. 

Wheel  transportation  includes  every  method  of  transpor- 
tation on  wheels  from  a  child's  express  wagon  to  the  latest 
thing  in  hosi)ital  trains.  Wherever  roads  are  at  all  ])assable, 
make  every  possible  use  of  wheel  trans])ortation.  For  long 
distances  it  is  almost  the  only  form  of  trans])ortation  which 
can  be  used.  The  transportation  by  litter  should  be 
exchanged  for  wheel  transportation  whenever  possible. 

In  war,  where  many  wounded  must  be  mo\'ed,  long  trans- 
portation by  litter  soon  exhausts  all  the  litter  bearers  and 
makes  the  removal  of  the  wounded  very  difficult.  It  is  hard 
work  to  carry  a  loaded  litter.  Try  it  yourself  some  time  and 
notice  the  fatigue  after  two  or  three  hundred  yards. 

If  called  u])on  to  move  a  wounded  man  a  long  distance, 
secure  the  best  available  means  of  transportation  but  don't 
despise  the  smallest  cart,  if  nothing  better  is  at  hand. 

THE    AMBULANCE. 

The  ambulance  is  a  specially  constructed  \'ehicle  for  the 
transportation  of  the  sick  and  injured.  It  may  be  horse- 
drawn  or  driven  by  motor.  In  the  European  war  the  motor- 
driven  ambulance  has  largely  supplanted  the  older  horse 
ambulances.  The  army  ambulances  are  arranged  to  carry 
four  patients  on  litters,  two  above  and  two  on  the  floor  of 
the  vehicle.  On  the  sides  are  two  hinged  seats,  which,  when 
not  in  use,  may  be  folded  against  the  sides.  These  seats 
may  be  used  for  patients  who  can  sit  up  so  that  the  ambu- 
lance will  carry  eight  patients  sitting,  or  four  recumbent. 
The  body  of  the  motor  ambulance  is  arranged  in  the  same 
way  as  a  horse-drawn  ambulance.  Beneath  the  seat  are 
carried  dressings,  splints  and  other  supplies. 


THE  AMBULANCE 


271 


oro 


TRAXsroirrATfo.w 


111  cities  tlio  ordinary  li(»si)ital  aiiil)ulancc  is  si^ldoin 
equipped  to  carry  more  than  two  patients. 

It  is  often  necessary  to  improvise  an  ainhulance.  l'\)r  a 
litter  patient  the  ordinary  touring  car  is  ue\er  satisfactory. 
Patients  who  are  able  to  sit  up  may  conveniently  he  trans- 
ported in  touring  cars  hut  recumhent  patients  require  a 
wagon  or  an  automohile  with  a  hody  hirge  enough  to  hold 
the  litter.  In  the  country,  where  litters  are  not  available, 
I  have  been  accumstomed  to  remove  the  legs  from  a  narrow 
cot  and  place  this  in  a  wagon  about  the  size  of  the  ordinary 
grocery  wagon.  The  springs  of  the  cot  form  a  nnich  more 
satisfactory  bed  than  the  hard  wagon  body.  In  addition 
the  patient  can  be  first  placed  on  the  cot,  which  forms  an 
improvised  litter,  and  can  thus  be  easily  moved  into  the 
vehicle. 

The  movement  of  a  recumbent  patient  by  train  may  be 
accompanied  by  many  difficulties.  The  ordinary  Pullman 
car  is  so  arranged  that  it  is  impossible  to  carry  a  litter  in 
tln-ough  tlie  narrow  hallway.  A  few  have  large  windows 
through  which  a  litter  may  be  passed,  ))ut  in  most  cases  the 
windows  are  much  too  narrow.  For  short  distances  I  have 
found  it  more  convenient  to  transport  a  litter  patient  on  a 
cot  in  the  baggage  car  than  to  attem])t  to  enter  the  Pullman 
or  day  coach.  For  long  distances  the  added  conveniences  of 
the  Pullman  are  of  so  much  advantage  that  if  it  is  impossil)le 
to  pass  the  litter  in  through  the  window  it  is  usually  justifi- 
able for  two  bearers  to  carry  the  patient  in  tln-ough  the  nar- 
row hallway.  The  leading  bearer,  who  walks  backward, 
holds  the  i)atient  beneath  the  armi)its  while  the  second 
supports  the  legs,  his  hands  clasped  beneath  the  patient's 
knees. 

In  the  army,  si)ecial  hos])ital  trains  are  fully  ecpiipped  for 
both  major  and  minor  surgery.  They  have  large  side  doors 
for  the  admission  of  patients.  In  case  of  a  railway  accident 
where  many  patients  are  injured  it  is  much  better  to  send 
freight  and  baggage  cars  to  bring  back  the  wounded,  than 
the  ordinary  passenger  cars  or  Pullmans. 

In  major  emergencies  it  is  sometimes  necessary  to  im])ro- 
vise  hospital  cars.    For  this  purpose  the  ordinary  freight  car 


THE  AMBULANCE 


273 


serves  better  than  either  passenger  coaches  or  Pulhnan  cars. 
The  stretchers  are  easily  passed  in  through  the  side  doors 
and  the  patients  placed  on  mattresses  on  the  car  floors. 
A  special  car  fitting  has  been  designed  which  is  used  in 
the  United  States  Army  and  permits  the  carrying  of  large 


Fig.  153. — Showing  the  interior  of  a  German  hospital  car.  The  cots  are 
movable  and  may  be  used  as  stretchers.  (Copyright  by  Brown  &  Dawson, 
Stanford,  Conn.,  from  Underwood  &  Underwood,  N.  Y.) 


numbers  of  patients  on  the  ordinary  army  litters.  The  lit- 
ters are  carried  in  tiers  of  three,  the  ends  being  supported 
by  iron  posts  fitted  snugly  in  the  floor  and  roof  of  the  car. 
From  cross-arms  on  these  iron  posts  are  suspended  iron  rings 
in  which  the  litter  handles  are  placed.  The  fittings  are 
ingeniously  made  so  as  to  fold  and  so  that  they  may  be 
18 


274 


TRAXSPORTATION 


onl;iri:;('(l  to  fit  freight  cars  varyinu;  in  luMi^lit.  The  riiii^s 
lioltlinu-  the  httor  handles  are  sus])cn(k'(l  by  springs  which 
irivc  a  ctTtain  amount  of  rcsihcnc\-  to  the  htter. 


Fig.  154.— Special  car  fittings  set  up  to  demonstrate  their  use  as  supports 
for  the  regulation  army  litters.  By  their  use  an  ordinary  freight  car  may 
be  quickly  transformed  into  a  hospital  car. 


Transportation  by  water  \aries  greatly,  depending  on  the 
type  of  vessel  available.  Usually  considerable  ingenuity 
must  be  exercised  in  transferring  the  patient  to  the  vessel 
or  from  one  vessel  to  another.  In  the  navy  a  special  rig  and 
tackle  is  arranged  to  load  and  unload  patients. 


CHAPTER  XIV. 

NURSING  AND  TECHNIC. 

In  a  book  devoted  to  first  aid  it  is  not  possible  to  treat 
exhaustively  the  principles  of  nursing.  It  is  desired,  however, 
to  outline  some  of  the  commonly  employed  procedures  so 
that  the  partially  trained  assistant  may  be  able  to  carry 
out  intelligently  the  orders  of  the  attending  physician,  or 
may,  in  case  of  need,  perform  the  simpler  duties  which  add 
greatly  to  the  comfort  of  the  patient. 

NURSING   METHODS. 

To  Prepare  the  Room, — ^The  sick  room  should  be  large  and 
cheerful.  There  should  be  plenty  of  windows,  preferably  of 
southern  exposure,  to  admit  fresh  air  and  sunlight.  It  should, 
if  possible,  contain  a  fireplace  both  for  ventilation  and  for 
warmth,  and  should  not  be  too  far  removed  from  the  bath 
and  toilet.  The  room  should  be  quiet  and  clean,  removed 
from  noise  and  odors  from  the  kitchen.  It  should  be  fur- 
nished with  a  bed  for  the  patient  and  a  cot  or  couch  for  the 
attendant,  or  two  beds. 

The  best  bed  for  patients  seriously  sick  is  a  narrow  iron 
bed  about  three  feet  wide  and  about  thirty  inches  from  the 
ground.  The  ordinary  half-size  bed  may  be  conveniently 
used,  placing  blocks  6  or  8  inches  in  height  under  the  legs  to 
raise  it  the  required  distance  from  the  ground.  This  is  impor- 
tant because  it  is  much  more  difficult  to  care  for  a  patient 
in  a  low  bed  than  in  a  high  one. 

The  curtains  should  be  of  washable  material,  and  there 
should  be  few  hangings  about  the  room. 

Of  course,  it  is  often  difficult  to  obtain  all  these  requhe- 
ments  in  the  ordinary  household.  I  consider  fresh  air  and 
sunlight  of  the  greatest  importance,  and  will  often  sacrifice 
a  great  deal  to  secure  a  sufficiency  of  both. 


270  NURSIXC   AXD   TFA'IIMC  . 

To  Make  the  Bed. —  A  firm  hair  mattress  makes  the  liest 
fouiuhitiou  for  a  sick  bed.  On  the  mattress  is  sjM-ead  a  l)hm- 
ket  or  (luilt  eoxered  with  a  sheet  which  is  spread  out  smootlily 
over  the  bed  and  tucked  in  on  all  sides. 

If  there  is  dauj^er  of  sailing  the  bed,  as  is  ai)t  to  be  the 
case  \\\\v\\  A\'et  (lressinfj;s  are  applied  or  when  a  bed-pan  is 
used,  a  piece  of  rubber  sheeting  is  ])laced  beneath  the  sheet 
or  between  it  and  the  draw-sheet. 

The  draw-sheet  is  made  by  foldiujj;  a  sheet  lenj;t]iwise  so 
as  to  make  it  half  its  original  width  and  then  i)lacing  it 
across  the  center  of  the  bed,  the  ends  of  the  sheet  being 
tucked  in  at  the  sides.  This  draw-sheet  should  be  kept 
smooth  and  firm.  It  may  be  shifted  a  little  se\eral  times  a 
day  so  that  the  i)atient  lies  on  a  clean  j)ortion. 

Over  the  patient  is  placed  a  sheet  and  one  or  more  blan- 
kets.   A  thin  counterpane  may  be  used  if  desired. 

To  Change  the  Sheets. — In  changing  the  lower  sheet,  roll 
the  i)aticnt  o\er  so  that  he  lies  on  the  left  side  of  the  bed. 
Then  starting  on  the  right  side  roll  tlie  sheet  lengthwise  into 
a  small  roll  next  to  the  patient.  Then  take  the  clean  sheet 
and  fold  it  lengthwise  in  narrow  folds  as  far  as  the  middle 
and  i)lace  the  folds  next  to  the  patient,  the  right  half  of  the 
sheet  covering  the  })ortion  of  the  bed  previously  uncoNcred. 
This  side  of  the  sheet  is  then  carefully  tucked  in  and  smoothed 
over  the  right  half  of  the  bed.  The  patient  is  now  rolled  to 
the  right  side  of  the  bed  over  the  folded  sheets,  the  soiled 
sheet  being  then  removed  and  the  clean  sheet  smoothed 
out  and  tucked  in  on  the  left  side.  The  rubber  sheeting  and 
the  draw-sheet  may  be  changed  in  the  same  way. 

To  change  the  upper  sheet  all  the  other  covers  are  removed 
and  the  clean  sheet  placed  directly  over  the  soiled  one. 
The  soiled  sheet  may  be  withdrawn  while  the  clean  one  is  hekl 
in  place,  the  change  being  made  without  exposing  the  patient. 

Care  of  the  Skin. — It  is  extremely  important  that  the 
patient's  skin  should  be  carefully  cared  for.  A  daily  bath 
should  be  given  and  the  bed  kept  dry  and  clean.  Crumbs 
should  l)e  carefully  l)rushed  awa>'.  The  back  should  be 
sponged  with  alcohol  and  well  powdered  with  talcum  at 
least  once  daily. 


NURSING  METHODS 


277 


Bed-sores. — In  poorly  nourished  patients  who  are  confined 
to  bed  for  long  periods  the  pressure  of  the  })ody  against  the 
bed  may  cause  the  formation  of  large  ulcers  on  the  liips, 
shoulders,  or  over  the  lower  end  of  the  spine,  liarely  these 
sores  may  occur  on  the  elbows  or  heels  or  at  othci-  parts  of 
the  body.  They  are  usually  the  direct  result  of  carelessness 
and  neglect. 


^^W'  :MV 

m 

^ 

^^^^^^r    ''-'^!«W™  .m. 

■«H 

^^^^B 

"i 

m      W^^^^ 

^\ 

'Si 

L'-^"^  ' '-  ■ 

A 

,^-*^lto^„ 

--------•-■---^'' 

..-^ 

Fig.  155. — Enormous  bed-sore  of  the  back  in  a  patient,  aged  seventy- 
eight  years.     (Ashhurst.) 

In  order  to  avoid  this  trouble,  persons  confined  to  bed  for 
long  periods  should  be  frequently  moved  in  bed  so  that  the 
same  spots  are  not  continually  pressed  upon  and  the  bed 
and  body  kept  dry  and  clean.  When  a  bed-sore  is  threat- 
ened, as  shown  by  a  slight  redness  of  the  skin,  the  bed  should 
be  arranged  so  that  absolutely  no  pressure  comes  at  the 
threatened  point.  This  can  be  accomplished  by  the  use  of 
pillows,  air  rings,  air  cushions  and  other  simple  appliances. 
The  affected  part  should  be  bathed  daily  with  50  per  cent, 
alcohol. 

Temperature. — A  patient's  temperature  is  taken  with  the 
ordinary  clinical  thermometer.  The  average  normal  tem- 
perature on  the  Fahrenheit  scale  is  said  to  be  98. G°.  As  a 
matter  of  fact  the  temperature  varies  at  different  times 
during  the  day  and  is  apt  to  be  as  low  as  97°  and  is  as  high 
as  99°  F.  in  normal  persons.    A  temperature  above  99°  F. 


278  NURSING  AND   TECH  NIC 

is  generally  considered  to  indicate  disease,  although  in  a 
few  cases,  such  as  after  \'iolent  exercise  and  in  very  wai-ni 
weather,  a  rise  to  100°  F.  may  be  without  significance. 

"^rhc  temperature  is  most  conveniently  taken  in  the  mouth, 
tiu'  l)ulh  of  the  thermometer  being  placed  beneath  the  tongue 
and  kept  in  place  from  oiu'  to  five  minutes,  depending  on 
the  thermometer  used. 

In  unconscious  ])atients  and  in  cliildren  it  is  better  to  take 
the  temperature  by  the  rectum.  The  thermometer  bulb  is 
smeared  with  ^'aselin  or  other  lubricant  and  inserted  into  the 
anus  for  an  inch  or  more  and  allowed  to  remain  until  the 
temperature  has  registered.  The  rectal  tem])erature  is 
usually  one-half  to  a  full  degree  higher  than  the  temperature 
in  the  mouth.  In  some  cases  the  t.emi)erature  is  taken  in 
the  armpit  (axillary  temperature),  but  this  is  unreliable. 
Of  the  three  methods  the  rectal  is  the  most  accurate  and  the 
axillary  the  least.  When  the  temperature  is  of  great  im])or- 
tance,  and  in  children  and  unconscious,  or  delirious,  i)atients 
the  rectal  method  should  be  used  exchisiveh'. 

The  clinical  thermometer  contains  only  a  slender  thread  of 
mercury,  which  is  most  difficult  to  read.  In  order  to  over- 
come this  difficulty  the  thermometers  are  usually  made  tri- 
lateral in  shape,  the  front  edge  which  is  curved  serving  as  a 
magnifying  glass  which  enlarges  the  thread  of  mercury. 
Consequently,  to  read  the  level  of  the  mercury  it  is  neces- 
sary to  hold  the  thermometer  directly  in  the  line  of  vision 
with  the  front  of  the  angle  toward  you.  \Yith  a  little  prac- 
tice the  le\'el  of  the  mercury  can  be  easily  made  out. 

All  thermometers  are  self-registering.  That  is,  the  level 
of  the  column  of  mercury  remains  at  the  highest  point. 
Thus  a  patient  may  take  his  temjierature  and  then  place 
the  thermometer  aside  to  be  read  by  the  })hysician  several 
hours  later.  Because  the  mercury  does  not  return  to  the 
bulb  of  its  own  accord  it  must  be  shaken  down  before  use. 
This  is  accomplished  by  holding  the  thermometer  in  the 
hand  and  swinging  sharply  downward,  as  though  "cracking" 
a  whip.  In  practice  the  mercury  need  not  be  shaken  entirely 
down  into  the  bulb.  Usually  a  point  between  90°  and  97° 
is  sufficient. 


NURSING  METHODS  279 

Some  thermometers  are  graduated  according  to  the  centi- 
grade scale.  In  this  scale  1°  equals  1.8°  F.  As  the  zero  of 
the  centigrade  scale  corresponds  to  32°  ¥.,  to  change  a 
centigrade  reading  to  the  Fahrenheit  multiply  by  9/5  and 
add  32.  Conversely,  to  change  F.  to  C.  subtract  32  and  mul- 
tiply by  5/9.  For  example,  to  convert  98.6°  F.  to  centigrade: 
98.6  —  32  =  66.6  X  5/9  =  37. 

Pulse. — If  the  fingers  are  laid  gently  on  any  superficial 
artery  the  beat  can  be  felt  and  counted.  This  is  called  the 
pulse.  The  radial  artery  is  usually  the  most  convenient  for 
the  purpose  of  taking  the  pulse.  It  is  located  on  the  thumb 
side  of  the  wrist  and  may  be  easily  felt  and  counted. 

The  pulse  should  be  counted  for  a  minute  and  the  rate 
given  as  so  many  beats  per  minute.  Ordinarily  we  speak  of 
the  pulse-rate  as  72  or  80,  meaning  72  or  80  beats  per  min- 
ute. In  addition  to  the  rate,  the  size  and  regularity  of  the 
pulse  should  be  noted.  An  intermittent  pulse  is  one  that 
drops  a  beat  occasionally,  while  an  irregular  pulse  is  one 
which  noticeably  varies  in  rate  or  size. 

We  say  that  the  normal  pulse  is  about  72,  but  it  varies 
considerably  in  different  people,  and  in  the  same  person  at 
different  times  during  the  day.  After  exercise  the  pulse 
may  reach  120  per  minute  or  even  higher,  but  in  healthy 
individuals  it  should  return  to  normal  within  a  short  time. 
When  the  pulse  is  below  60  it  should  cause  suspicion  of  heart 
disease,  and  when  above  90  it  would  suggest  the  possibility  of 
fever.  A  pulse  which  is  irregular  in  either  force  or  frequency 
usually  indicates  some  form  of  heart  disease.  With  a  tem- 
perature of  100°  we  would  expect  a  pulse  count  of  100  and 
when  the  temperature  is  103°  the  pulse  is  apt  to  be  between 
110  and  120.  However,  these  figures  are  subject  to  wide 
variations,  such  a  simple  thing  as  the  excitement  of  a  physical 
examination  often  sending  the  pulse  to  120  or  higher. 

In  children  the  pulse  is  normally  much  faster.  The  normal 
rate  in  infancy  varies  between  100  to  120  and  may  rise  to 
140  or  higher  during  tnild  febrile  attacks.  As  the  child  grows 
older  the  pulse  becomes  slower. 

Respiration. — The  rate  of  respiration  has  a  definite  rela- 
tion to  the  pulse,  being  approximately  one-fourth  the  pulse- 


280  NVR.'^IXC;  AXD   TECIIXIC 

rate.  ^Yhen  the  rate  of  respiration  is  increased,  especially 
when  it  is  increased  relatively  more  than  the  pulse,  it  may 
indicate  disease  of  the  lungs,  such  as  pneumonia.  In  opium- 
])ois()nin,»;  the  res])iration  may  be  very  slow,  sometimes  not 
over  eight  per  minute. 

In  taking  the  respiration-rate  it  must  be  remembered  that 
breathing  is  partially  controlled  by  the  will,  so  that  if  the 
patient  realizes  that  you  are  watching  him  l)reathe  he  will 
imconsciously  change  the  rate.  It  is  a  good  ])lan  to  take  the 
pulse,  and  then  while  still  holding  the  wrist  obser\'e  the 
patient's  breathing  without  his  being  aware  of  the  fact. 

We  may  say  that  breathing  is  noisy,  regular,  irregular, 
quiet,  easy,  difficidt,  using  any  descri})tive  term. 

Dyspnea  means  difficult  breathing  from  any  cause. 

Tongue. — The  condition  of  the  tongue  should  be  noted. 
It  is  clean  and  moist  in  health,  but  in  disease  may  be  dry 
or  coated.  A  coated  tongue  usually  indicates  some  disturb- 
ance of  the  gastro-intestinal  tract. 

In  fever  the  tongue  is  apt  to  be  dry,  and  may  become 
cracked  and  sore  if  neglected.  During  sickness  the  mouth 
and  tongue  should  be  scrupulously  cared  for,  the  teeth  should 
be  brushed,  and  an  alkaline  mouth  wash^  should  be  used 
after  each  meal.  If  the  tongue  is  dry  or  cracked  it  should  be 
wiped  off'  with  a  mixture  containing  equal  parts  of  glycerin, 
lemon  juice,  and  water. 

BATHS    AND   BATHING. 

Baths  are  given  for  purj^oses  of  cleanliness  or  for  purposes 
of  treatment.    In  general,  baths  may  be  given: 

1.  To  cleanse  the  body. 

2.  To  reduce  fever. 

3.  To  cjuiet  the  nervous  system. 

4.  To  induce  sweating. 

Baths  may  be  classified  according  to  temperature  as  hot 

'  Bicarbonate  of  soda  solution,  1  teaspoonful  to  a  glass  of  water,  may  be 
used,  or  almost  any  of  the  widely  advertised  mouth  washes  may  be  substi- 
tuted for  the  soda  solution.  The  aromatic-  flavor  of  the  commercial  washes 
is  sometimes  desirable. 


BATHS  AND  BATHING  281 

baths  (100°  to  105°  F.),  tepid  baths  (90°  to  100°  F.),  and  cold 
baths  (70°  to  85°  F.). 

Naturally,  when  a  patient  is  not  too  sick  the  tub  bath 
should  be  given  for  cleansing  purposes.  It  must  be  remem- 
bered, however,  that  the  bath  may  be  very  weakening,  so 
that  when  a  sick  person  attempts  to  take  a  tub  bath  a  close 
watch  should  be  kept  by  the  attendant  in  order  to  be  sure 
that  fainting  does  not  take  place  while  the  patient  is  in  the 
tub. 

Sponge  Baths. — Patients  confined  to  bed  should  receive  a 
daily  sponge  bath.  In  order  to  give  the  sponge  bath,  a  rubber 
sheet  covered  M'ith  a  blanket  should  be  placed  over  the  bed 
in  the  same  manner  as  has  been  outlined  for  changing  the 
lower  sheet.  The  patient  is  covered  with  a  sheet  and  the 
body  sponged  with  a  sponge  or  wash  cloth  wet  in  warm, 
soapy  water.  One  part  of  the  body  is  washed  at  a  time, 
rinsed  off  with  clean  water  and  dried  before  starting  on 
another  part.  The  daily  bath  is  usually  given  in  the  morning 
and  the  bedding  changed  after  the  bath. 

The  sponge  bath  is  sometimes  given  to  reduce  temper- 
ature. When  it  is  given  for  this  purpose  the  entire  body  is 
exposed  and  the  water  applied  at  a  temperature  of  about 
80°  F.  If  the  patient  seems  chilly  during  the  bath  a  little 
broth  or  hot  milk  may  be  given. 

Alcohol  Sponge. — ^This  is  very  easy  to  give.  It  tends  to 
reduce  temperature  and  acts  as  a  sedative  to  the  nervous 
system.  A  wash  cloth  or  sponge  is  wrung  out  of  a  mixture  of 
equal  parts  of  alcohol  and  warm  water  and  used  to  sponge 
off  the  body.  To  be  the  right  temperature  the  cloth  should 
feel  a  little  more  than  tepid  to  the  hand  (about  100°  F.). 

In  giving  the  sponge  all  the  covers  are  removed  from  the 
patient  but  the  sheet,  and  the  alcohol  is  applied  to  the  body 
beneath  the  sheet,  without  exposing  the  patient.  After  the 
front  of  the  body  has  been  well  gone  over  with  the  sponge 
the  patient  is  turned  over  and  the  remainder  of  the  body 
sponged  in  the  same  way.  The  body  is  not  dried,  the  alcohol 
being  allowed  to  evaporate. 

In  fever  patients,  a  fall  in  temperature  of  a  degree,  or  a 
degree  and  a  half,  after  an  alcohol  sponge  is  not  unconunon. 


2S2  NVRSIXC   AXD   TECIIXIC 

It  also  often  liai)i)ens  that  after  tlio  spoii.i2;o  the  patient, 
previously  nervous  and  restless,  will  drop  quietly  ott"  to  sleep. 

Tub  Baths. — A  hot  bath  may  be  given  for  the  purpose  of 
inducing  ])erspiration,  or  for  relaxation  in  certain  nervous 
conditions.  Tiie  temperature  of  the  l)ath  is  usually  about 
10.")°  F.,  and  the  duration  from  ten  to  fifteen  minutes. 

In  order  to  o;i\'e  a  tub  bath  properly  in  typhoid  fever  a 
movable  tub  is  required  which  can  be  moved  next  to  the 
patient's  bed.  Typhoid  baths  are  usually  <2;iven  at  about 
S()°  to  90°  F.  The  patient  is  carefully  lifted  into  the  tub  by 
four  attendants  and  allowed  to  lie  quietly,  the  head  resting 
on  a  sui)port  at  one  end  of  the  tub,  and  a  wet  cloth  applied 
to  the  forehead.  During  the  bath  the  entire  body  should  be 
rubbed  contiiniously,  in  order  to  increase  the  superficial 
circulation. 

While  in  the  bath  the  patient  feels  cold,  the  teeth  chatter, 
and  the  skin  turns  bluish.  If  the  \n\he  grows  rapid  and  weak 
the  bath  should  be  stoi)pe(l. 

After  removing  the  patient  from  the  tub  he  should  l)e 
placed  in  bed  on  a  blanket  and  I'ubbed  l)riskly  with  a  rough 
towel.  A  drink  of  hot  broth  is  then  gi\'en  and  a  hot-water 
bottle  placed  at  the  feet. 

Ice  Baths. — In  cases  of  sunstroke,  baths  may  be  given  as 
described  above,  except  that  the  water  may  be  much  colder, 
about  50°  to  60°  F.  In  order  to  keep  the  temperature 
low,  cold  water  must  be  constantly  added  or  a  few  pieces  of 
ice  may  be  put  into  the  tub.  During  the  bath  the  rectal 
temperature  should  be  taken  at  intervals  and  the  patient 
removed  from  the  tub  while  the  temperature  is  still  several 
degrees  above  normal.  The  after-treatment  is  the  same  as 
for  cold  baths. 

Hot  Packs. — These  produce  sweating  nearly  as  well  as 
hot  l)aths,  and  are  less  disturbing  to  the  patient. 

The  bed  is  protected  with  a  rubber  sheet,  over  which  a 
blanket  is  placed,  and  the  patient's  clothes  entirely  removed. 
A  blanket  is  now  wrung  out  of  hot  water  (about  120°  F.)  and 
the  patient  wrapped  in  this  wet  l^lanket.  The  blanket  when 
it  reaches  the  patient  is  usually  not  more  than  1 10°  F.  Plenty 
of  drinking  water  should  be  given,  so  that  the  perspiration 


BATHS  AND  BATHING  283 

will  be  profuse.  The  patient  is  allowed  to  remain  in  pack 
from  fifteen  to  twenty  minutes.  An  ice-cap  or  cold  com- 
press is  kept  on  the  head  and  the  pulse  taken  at  intervals 
during  the  pack.  If  the  pulse  becomes  rapid  and  weak  the 
treatment  should  be  stopped. 

After  the  pack  the  body  is  rubbed  dry  with  a  towel  and 
the  patient  left  between  dry  blankets  for  about  an  hour. 
At  the  end  of  this  period  an  alcohol  rub  is  given,  the  body 
dried,  and  the  patient  made  comfortable  with  clean,  dry 
linen. 


Fig.  156. — A  hot  pack  being  given  in  a  case  of  uremia.     Note  the 
arrangement  of  the  blankets.     (Hare.) 

Sweat  Baths. — ^There  are  several  methods  of  inducing  sweat- 
ing by  the  use  of  modified  hot  packs.  The  simplest  consists 
of  placing  the  patient  between  blankets  surrounded  by  hot- 
water  bottles  (ordinary  glass  bottles  filled  with  hot  water 
serve  very  well  in  an  emergency)  and  then  covering  him  with 
several  blankets.     This  usually  quickly  induces  sweating. 

Another  method,  sometimes  called  a  "rimi  sweat,"  con- 
sists in  surrounding  the  patient  with  hot  bricks  well  wrapped 
in  cloths.  On  these  bricks  raw  whisky  or  rum  is  poured  and 
the  patient  covered  with  several  layers  of  blankets.  The 
steam  from  the  hot  bricks  surrounds  the  patient  and  soon 
causes  sweating.  Care  must  be  taken  that  the  hot  steam 
does  not  cause  burns. 


284  NURSING  AND  TECHNIC 

Of  course  the  ])atient  must  be  given  plenty  of  water  during 
the  sweat  and  the  head  must  be  kept  cool,  just  as  during  the 
hot  pack.  The  after-treatment  is  the  same  as  that  after  the 
hot  ]);u'k.  Ncxcr  allow  tlie  body  and  bed-linen,  wet  with 
perspiration,  to  remain  unchanged  for  more  than  an  hour  or 
two  after  the  sweat. 

Foot-baths.— It  is  sometimes  desirable  to  secure  dilatation 
of  the  vessels  in  one  part  of  the  body  so  that  the  blood  may 
be  drawn  from  another  part.  Thus,  a  hot  foot-bath  is  sup- 
posed to  have  a  fa\'oral)le  action  in  colds  in  the  head  and 
some  cases  of  headache.  The  patient,  well  wrapped  up, 
places  the  feet  in  hot  water,  which  comes  to  a  level  well 
above  the  ankles.  The  water  is  kept  as  hot  as  can  })e  borne 
by  ])ouring  hot  water  into  the  tub  from  time  to  time  and  the 
bath  continued  for  about  fifteen  minutes. 

Sitz  Baths. — This  is  somewhat  similar  to  the  foot-bath, 
exce])t  that  the  patient  is  seated  in  the  water,  the  level  of 
which  extends  up  o\'er  the  hips. 

Medicated  Baths. — In  some  cases,  for  purposes  of  counter- 
irritation  or  stimulation,  other  substances  may  be  added  to 
the  water.  Thus  sea  salt,  or  common  salt,  is  valuable  in 
certain  diseases,  the  quantity  to  be  added  to  the  water  vary- 
ing from  one  to  three  pounds. 

Ordinary  Epsom  salts  have  recently  been  advised  for  the 
purj)()se  of  reducing  weight.  About  a  pound  is  added  to  a 
tub  half-full  of  water  and  a  twenty-minute  bath  taken.  The 
value  of  this  treatment  is  largely  due  to  the  hot  bath  and 
only  slightly  to  the  content  of  salts. 

Two  or  three  tablespoonfuls  of  mustard  are  often  added 
to  hot  foot-baths  or  even  to  the  general  bath.  It  is  commonly 
believed  that  the  counter-irritation  adds  to  the  efl'ect  of  the 
liot  hath. 

EXTERNAL   APPLICATIONS. 

The  Apphcation  of  Heat. — Heat  may  be  a])i)licd  dry  or  wet. 
Tlic  most  common  form  of  dry  heat  is  the  hot-water  bag. 
Although  in  connnon  use  the  correct  method  of  using  the 
hot-water  bag  is  not  generally  understood. 

The  bag  should  be  only  two-thirds  full  and  shcMild  never 


EXTERNAL  APPLICATIONS  285 

contain  boiling  water.  Patients  are  frequently  burned  witli 
bags  containing  water  which  is  too  hot,  so  that  it  is  always 
advisable  to  test  the  bag  by  placing  it  against  the  forearm 
for  a  short  period.  If  it  cannot  be  borne  against  th(;  skin 
it  should  not  be  placed  in  the  patient's  bed,  especially  if  the 
patient  is  asleep  or  only  partially  conscious. 

If  there  are  not  sufficient  hot-water  bags  at  hand,  tin 
cans,  glass  bottles,  or  any  other  suitable  receptacles  may  be 
used.  Hot  salt-bags,  hot  bricks,  electric  heaters,  or  dry  air 
may  also  be  used.  Recently  the  ordinary  incandescent  lamp 
has  been  widely  used  for  the  local  application  of  heat. 

Hot-water  bags  may  burst  or  leak  in  the  bed.  They  should 
be  carefully  tested  before  use.  Hot  bricks  are  heavy  and 
awkward,  but  they  retain  their  heat  for  a  long  time. 

Moist  heat  is  supposed  to  be  more  penetrating  and  relax- 
ing than  dry  heat.  It  may  be  used  in  the  form  of  hot  com- 
presses, poultices,  or  stupes. 

Hot  Compresses. — Several  layers  of  gauze  are  wrung  out  of 
hot  water  and  applied  to  the  body  before  they  have  an  oppor- 
tunity to  cool.  They  may  be  covered  with  cotton  or  oiled 
silk  and  left  in  place  for  ten  minutes  or  longer,  or  they  may 
be  changed  after  a  few  minutes  when  they  begin  to  grow 
cold. 

Stupes. — ^A  stupe  consists  of  about  two  layers  of  flannel 
wrung  out  of  hot  water  and  covered  with  a  towel  or  piece  of 
oiled  silk.  To  wring  out  a  stupe  it  should  be  placed  in  a 
towel  and  the  water  wrung  out  by  twisting  the  dry  end  of 
the  towel;  or  a  hem  may  be  sewn  in  each  end  of  the  towel 
large  enough  to  admit  the  passage  of  a  thin  stick  of  wood  at 
each  end.  These  two  sticks  serve  as  handles  with  which 
to  wring  out  the  stupes  which  are  lifted  from  the  water  with 
a  stick.  After  it  is  wrung  out,  a  stupe  is  tested  with  the  hands 
and  placed  in  position  as  soon  as  the  patient  can  stand  it. 
It  should  be  changed  every  five  minutes. 

Turpentine  Stupes. — These  are  given  exactly  as  the  ordi- 
nary stupes,  except  that  the  counter-irritation  is  increased 
by  the  use  of  turpentine.  The  most  satisfactory  way  to 
apply  the  turpentine  is  to  wet  the  surface  of  the  skin  with 
spirits  of  turpentine  before  applying  the   stupes.     These 


286  .  NURSING  AND   TECH  NIC 

stupes  should  never  be  applied  continuously,  or  the  skin  at 
the  point  of  treatment  will  become  irritated  and  inflamed. 
When  continuous  action  is  reciuired  the  stupes  may  be  used 
for  thii-t\'  iiiimitcs  (>\'cry  three  or  four  hours. 

Flaxseed  Poultice. — This  is  made  by  mixing  flaxseed  meal 
slowly  into  boiling  water  until  a  thick  paste  is  formed.  It  is 
then  cooked  for  about  five  minutes  and  removed  from  the 
fire  and  well  beaten  to  make  it  light.  The  mass  is  then 
spread  upon  a  piece  of  cotton  cloth,  forming  a  layer  about 
one-fourth  of  an  inch  in  thickness.  The  excess  of  cloth 
should  extend  about  one  inch  on  all  sides.  This  edge  is 
turned  over,  preventing  the  spread  of  the  flaxseed,  and  the 
surface  of  the  poultice  is  covered  with  a  i)iece  of  very  thin 
gauze.  The  gauze  is  i)laced  against  the  i)atient's  skin,  care 
being  taken  not  to  burn  him.  A  poultice  may  be  left  in 
])lace  for  about  an  hour  and  should  never  be  used  a  second 
time.  If  continuous  poulticing  is  desired  the  second  j)oultice 
should  be  ready  before  the  first  is  removed. 

If  flaxseed  is  not  obtainable,  oatmeal  or  cornmeal  may  be 
used. 

Mustard  Plaster. — One  part  of  mustard  is  mixed  with  four 
or  hve  parts  of  flour,'  sufficient  lukewarm  ^^'ater  being  added 
to  make  a  paste.  This  mixture  is  smeared  in  a  thin  layer 
upon  a  thin  piece  of  gauze  and  the  plaster  held  in  place  by 
a  bandage.  Never  make  a  mustard  plaster  with  hot  water, 
for  by  this  means  part  of  the  strength  of  the  mustard  is 
destro\'ed. 

The  plaster  should  be  left  in  place  until  the  skin  is  red- 
dened— about  twenty  minutes — and  then  removed.  Never 
go  away  and  forget  the  plaster,  for  if  it  is  left  on  too  long 
l)listering  will  surely  result.  After  the  plaster  has  been 
removed  a  little  vaselin  may  be  applied  to  the  reddened  skin. 

Cold  Compresses. — These  are  very  similar  to  hot  compresses, 
except  that  they  are  wrung  out  from  cold  water.  Consid- 
erable reaction  may  be  secured  from  the  cold  compress 
applied  to  the  body  and  then  covered  with  a  towel  or  piece 
of  oiled  silk.    At  first  the  skin  is  pale,  but  after  a  short  period 

1  For  children  the  plaster  should  be  weaker,  1  part  of  mustard  to  8  or  9 
parts  of  flour. 


COUNTER-IRRJTANTS  287 

reaction  sets  in  and  the  skin  })ecomes  flushed  and  warm. 
These  compresses  should  be  changed  about  once  an  hour. 

When  compresses  are  applied  solely  for  the  effect  of  cold 
they  should  be  changed  every  few  minutes  because  the  com- 
press becomes  quite  warm  after  ten  to  fifteen  minutes. 

The  Ice-bag. — ^This  is  a  rubber  bag  with  a  large  screw  top. 
Small  pieces  of  ice  are  placed  in  the  bag  with  a  little  water 
and  the  top  screwed  on,  care  being  taken  to  expel  all  the  air 
before  fastening  on  the  top. 

Never  apply  an  ice-cap  directly  to  the  skin.  If  it  is  not 
separated  from  the  skin  by  the  use  of  thin  gauze,  or  other 
material,  a  frost-bite  of  the  skin  may  result,  a  so-called  "ice- 
cap burn."  The  ice-cap,  if  the  skin  be  protected  in  the  manner 
just  described,  may  be  left  on  continuously.  The  ice  must 
be  renewed  about  every  two  hours. 

COUNTER-IRRITANTS. 

These  are  usually  chemicals  which,  when  placed  in  contact 
with  the  skin,  cause  redness  and  irritation.  They  relieve 
pain  and  deep  inflammation  by  their  action  upon  the  blood- 
vessels, increasing  the  circulation  not  only  in  the  skin  but 
also  in  the  deeper  parts.  Counter-irritants  may  cause  sim- 
ply a  reddening  of  the  skin  (rubefacients)  or  they  may  pro- 
duce blisters  (vesicants) . 

While  the  ordinary  counter-irritants  are  chemical  sub- 
stances, such  as  iodin  or  oil  of  mustard,  yet,  under  certain 
circumstances,  physical  forms  of  counter-irritation  may  be 
used. 

The  simplest  form  of  physical  counter-irritation  is  that 
due  to  the  rubbing  of  the  skin.  We  all  recognize  that  many 
of  the  small  pains  may  be  "rubbed  away."  In  general  it  is 
better  to  rub  toward  the  heart.  That  is,  in  such  a  manner 
as  to  empty  the  superficial  veins  by  rubbing  them  in  the 
direction  of  the  venous  flow.  INIassage  is  simply  scientific 
rubbing. 

In  rubbing  a  painful  area  of  the  body  the  skin  is  soon  apt 
to  become  sore  as  a  result  of  friction  vmless  some  form  of 
lubricant  is  used,  such  as  vaselin  or  talcum  powder. 


2S&  NURSING  AND  TECH  NIC 

Electricity. — Electricity  is  anotlicr  form  of  couuter-irrita- 
tioH.  It  may  be  used  either  in  the  form  of  an  electric  cur- 
rent or  throuj^h  the  medium  of  the  .r-rays  or  thermic  spark. 
The  action  of  the  .r-rays  and  electricity  is  only  partially  com- 
prehended and  their  use  is  not  without  danfi;er.  They 
should,  consequently,  be  employed  only  under  skilled 
direction. 

The  Cautery. — This  is  sometimes  called  the  actual  cautery 
and  is  simply  a  metal  instrument  heated  to  a  cherry-red 
color  used  to  relieve  pain,  to  cause  absorption  of  efl'usion, 
and  to  control  bleeding. 

In  hosi)itals  the  Paquelin  cautery  is  used.  This  is  an 
instrument  with  a  platinum  tip,  hrst  heated  in  the  flame 
of  an  alcohol  lamp  and  maintained  incandescent  by  a  small 
stream  of  gasoline  or  benzine  vapor  which  is  pumped  into  the 
tip  by  a  small  rubber  bulb.  This  is  similar  to  the  cautery 
which  has  come  into  po})ular  usage  in  the  art  of  pyrograi)hy. 

In  using  the  actual  cautery  the  red-hot  instrument  is 
made  to  touch  the  skin  lightly  at  many  separate  points  over 
the  painful  area.  The  instrument  is  kept  in  motion  and 
touches  the  skin  only  for  a  fraction  of  a  second.  If  this  is 
properly  performed  the  skin  will  barely  be  seared  and  there 
will  be  no  })lister  formation. 

Cupping. — Dry  cups  not  only  cause  counter-irritation  but 
actually  cause  an  extravasation  of  blood  beneath  the  skin. 
They  act  through  suction  caused  by  the  application  of  a  cup 
containing  heated  air  against  the  skin,  the  cooling  of  the  air 
in  the  cup  causing  a  vacuum  which  tends  to  draw  the  skin 
upward  into  the  cup.^r 

To  cup  a  ])atient  about  a  dozen  cujis  are  required.  These 
are  small  thick  glasses  about  one-third  the  size  of  the  ordi- 
nary tumbler.  A  swab  is  made  by  wrajjping  a  little  cotton 
tightly  about  the  end  of  a  probe.  This  is  dij)ped  in  alcohol 
and  lighted,  forming  a  small  torch. 

One  of  the  cups  is  now  taken  in  the  left  hand  and  the 
burning  torch  held  inside  of  it  for  an  instant  to  exhaust  the 
air,  after  which  the  cup  is  placed  quickly  against  the  skin 
and  held  in  place.  The  skin  can  be  seen  to  be  drawn  up  into 
the  cup.    This  procedure  is  repeated  until  the  required  num- 


COUNTER-IRRITANTS 


289 


ber  of  cups  are  applied.  In  applying  the  cuj)S  be  careful 
not  to  get  the  edges  too  hot,  and  not  to  allow  the  alcohol  to 
trickle  down  inside  of  the  cup.  A  little  practice  on  yourself 
will  soon  tell  you  how  long  the  torch  should  be  left  inside 
the  cup,  and  will  demonstrate  to  you  how  necessary  it  is  to 
avoid  heating  the  edges  of  the  cup. 

To  remove  the  cup,  press  the  skin  away  on  one  side,  thus 
allowing  the  air  to  enter  the  cup,  which  then  falls  off.  Each 
cup  is  left  in  place  from  three  to  ten  minutes.  It  is  then 
removed  and  replaced  after  exhausting  the  air  again.  After 
use  the  inside  is  covered  with  moisture  so  that  each  cup 
must  be  dried  before  it  can  be  reapplied.    Cupping  may  be 


Fig.  157. — Cups  applied  to  the  back.     (Hare.) 


done  several  times  daily,  usualh"  being  carried  on  over  a 
period  of  fifteen  to  thirty  minutes  at  each  application.  There 
is  no  danger  in  placing  a  cup  several  times  over  the  same 
spot. 

In  some  cases  the  suction  may  be  so  great  that  a  black- 
and-blue  spot  results.  This  has  no  harmful  consequences  and 
will  disappear  after  a  few  days. 

Wet  cups  are  sometimes  given  by  a  physician.  They  are 
exactly  the  same  as  dry  ones,  except  that  small  incisions 
are  first  made  in  the  skin  with  a  sharp  knife. 

Tincture  of  lodin. — ^This  is  a  chemical  irritant  and  is  applied 
to  the  skin  with  a  brush.  If  the  skin  is  tender  it  may  blister. 
Ordinarily  it  is  painted  on  the  skin  and  is  allowed  to  dry, 
19 


290  NURSlXa  AXD   TECIIMC 

reciniriiiix  no  further  ctuv.  It  sliould  l)o  ap])lie(l  licavily 
eiiouji;li  to  give  a  moderately  dec^p  brown  color.  After  a  few 
minutes  there  is  a  slight  hurning  sensation. 

If  there  is  a  severe  l)urniug  sensation  it  has  been  used  in 
too  strong  solution  or  too  much  has  been  applied.  The 
excess  should  be  remo\'ed  with  alcohol. 

The  action  of  tincture  of  iodin  as  a  counter-irritant  nuist 
not  be  confused  with  its  use  in  wounds.  In  wounds  it  is 
used  solely  for  its  antiseptic  properties  and  in  no  way  for 
counter-irritation.  It  is  merely  a  coincidence  that  it  ha])pens 
to  be  usefid  for  both  purposes. 

Liniments. — INIany  difi'ereiit  liniments  are  used  for  counter- 
irritation.  The  rul)}>ing  that  accompanies  the  application 
of  the  liniment  often  does  more  good  than  the  liniment. 
All  the  \arious  liniments  contahi  some  substances  which  in 
themselves  act  as  irritants,  (liloroform,  capsicum,  men- 
thol, and  camphor  in  watery  or  alcoholic  solutions  are  the 
substances  most  commonly  used.  Chloroform  liniment  is 
generally  harmless  and  widely  used.  It  should  l)e  allowed  to 
evaporate  before  a  bandage  is  applied,  as  other\\'ise  it  may 
cause  blistering. 

Cantharides,  or  Spanish  fly,  is  extremely  irritating  to  the 
skin.  It  is  sometimes  used  in  the  form  of  cantharides  plas- 
ter and  left  on  for  six  to  eight  hours,  to  cause  blister  forma- 
tion. If  the  blister  does  not  occur  by  that  time  the  canthar- 
ides plaster  should  be  removed  and  a  flaxseed  ])oultice 
applied.  This  usually  raises  the  blister  promptly.  Blisters 
are  seldom  used,  because  they  may  !)ccomc  infected  and 
result  in  troublesome  sores. 

Ointments. — Many  of  the  drugs  (menthol,  camphor,  oil  of 
wintergreen,  etc.)  commonly  used  in  the  form  of  liniments 
may  be  combined  with  vaselin  or  other  similar  vehicle  to 
form  ointments.  These  may  be  rubbed  into  the  skin  or 
smeared  on  and  covered  with  cotton. 

Because  ointments  may  sometimes  be  used  as  counter- 
irritants  it  does  not  follow  that  all  ointments  are  irritating 
to  the  skin.  The  name  ointment  sim])ly  indicates  a  semi- 
solid oily  substance  which  may  be  ai>plicd  to  the  skin.  Ordi- 
narily, ointments  are  bland  an<l  healing.    Special  ointments, 


ST  K  HI  LIZ  A  TION  29 1 

such  as  wintergrecn  ointirKMit  or  capsicum  ointment,  may 
act  as  counter-irritants  by  virtue  of  the  drugs  they  contain. 
A  word  of  warning  should  be  given  in  reference  to  all  forms 
of  counter-irritants.  There  is  a  limit  to  the  ability  of  the 
skin  to  withstand  counterirritation  for  more  than  a  few 
days.  When  the  skin  remains  reddened  and  shows  a  number 
of  small  reddish  elevations  (that  is,  an  eruption)  between  the 
periods  of  application  of  the  particular  counter-irritant,  the 
treatment  should  be  omitted  for  two  or  three  days  in  order 
to  allow  the  skin  to  regain  its  normal  appearance. 

STERILIZATION. 

Anyone  who  is  called  on  for  first  aid  or  who  assists  a  phy- 
sician in  the  care  of  patients  may  be  required  to  prepare 
instruments  and  supplies.  The  various  forms  of  steriliza- 
tion will  be  given,  the  attempt  being  made  to  indicate  in 
detail  those  procedures  which  may  be  carried  out  in  an 
ordinary  household. 

Instruments. — These  are  easily  sterilized.  A  basin  is 
secured  large  enough  so  that  all  the  instruments  may  be 
covered  with  water  and  the  instruments  allowed  to  boil 
from  five  to  ten  minutes.  In  order  to  prevent  rust  a  little 
sodium  carbonate  (washing  soda)  may  be  added  to  the  water. 

Sharp  instruments,  such  as  knives  and  scissors,  become 
quickly  dulled  if  often  boiled.  Consequently,  some  surgeons 
prefer  to  sterilize  sharp  instruments  in  a  tray  containing  70 
per  cent,  alcohol.  This  is  not  as  satisfactory  a  form  of 
sterilization  as  boiling. 

In  emergencies  all  the  instruments  may  be  sterilized  in 
alcohol  or  other  form  of  chemical  disinfectant.  For  a  single 
instrmnent  such  as  a  knife  or  probe,  the  plan  of  dipping  one 
end  of  the  instrument  into  pure  phenol  and  then  Avashing 
oft*  the  excess  with  alcohol  gives  very  good  results. 

A  5  per  cent,  solution  of  carbolic  acid  may  be  used  when 
it  is  impossible  to  secure  heat,  the  instruments  being  prefer- 
ably left  in  the  solution  for  a  half-hoiu"  or  longer. 

Solutions. — Water  and  salt  solution  are  the  two  liquids 
most  commonly  requiring  sterilization.     They  may  be  steri- 


292  NURSING  AND   TECIINIC 

lizod  l>y  hoiliiit;.  Tu  jHTpariug  solutions  for  the  i)liysici;m  it 
is  well  to  have  two  large  \essels  of  boiled  water,  one  hot 
and  another  which  has  been  allowed  to  cool.  When  needed 
these  may  be  mixed  together  so  that  a  solution  of  the  ]>ro])er 
temperature  may  be  obtained. 

Antise])ti{'  solutions  should  ])referal)ly  be  made  with 
boiled  water,  but  when  it  is  not  obtainable  they  may  be 
prepared  from  ordinary  tap  water  which,  as  a  rule,  contains 
very  few  l^acterla. 

Glassware  and  Graniteware. — Boiling  is  a  suitable  method 
for  the  sterilization  of  basins,  jars,  bottles,  glass,  graduates, 
and  other  similar  supplies,  but,  owing  t(i  their  bulk,  it  is 
frequently  impracticable  to  boil  them  all.  In  such  cases  a 
large  tank  of  bichloride  of  mercury  solution  (1  to  1000)  is 
prei)ared  and  the  sui)])lies  left  in  this  solution  for  several 
hours.  If  the  ware  is  clean  this  solution  will  kill  ])ra('tically 
all  the  organisms.  If  desired,  weak  carbolic  acid  may  be 
used  in  the  same  way. 

Never  place  the  bichloride  solution  in  direct  contact  with 
any  form  of  metal,  as  the  mercury  combines  with  tlie  metal, 
causing  rapid  corrosion. 

Towels  and  Dressings. — In  hospitals  and  surgical  supi)ly 
houses  towels  and  dressings  are  sterilized  in  a  special  appa- 
ratus called  an  autoclave,  by  the  use  of  steam  under  ])ressure. 

In  emergency  practice  they  are  the  most  difficult  form  of 
sup])lies  to  sterilize  satisfactorily.  Consequently,  it  is 
advisable  to  carry  a  sufficient  supply  sterilized,  wra]>ped  in 
cotton,  or  muslin,  covering  or  in  sealed  i)ackets,  ready  for  use. 
The  interif)r  of  such  packets  remains  sterile  for  a  long  time. 

For  an  emergency  dressing  a  jnece  of  gauze  may  be  boiled, 
or  wet  with  50  per  cent,  alcohol,  })ut  this  is  far  inferior  to 
dry  gauze. 

A  sterilizing  apparatus  similar  to  the  Arnold  sterilizer  may 
be  impro\'ised  by  making  a  wire  basket  which  will  hang 
inside  an  ordinary  wash-boiler  and  placing  small  packages 
of  dressings  or  towels,  carefully  wrapped  in  a  protective 
covering  of  muslin,  in  this  improvised  basket.  Water  is 
then  poured  into  the  boiler,  which  is  then  covered  and 
placed  on  the  stove.    After  the  water  has  boiled  for  at  least 


STERILIZATION 


2% 


an  hour  the  dressings  are  removed  and  placed  in  the  oven  to 
dry.  When  fully  dry  the  dressings  are  ready  for  use.  Care 
must  be  taken  not  to  burn  the  dressings  in  the  hot  oven. 


Fig.  158. — Autoclave  sterilizer  used  in  hospitals.     (Brewer.) 

Hands  and  Skin. — The  sterilization  of  the  hands  has 
already  been  discussed  in  the  chapter  devoted  to  Wounds. 
Remember  that  a  thorough  scrubbing  ^^■ith  soap  and  water 
is  much  better  than  perfunctory  dipping  in  antiseptic 
solutions. 


294 


XrRSIXa   AM)    TKCIIXIC 


III  (ii-(k'r  to  pivparc  the  ]);iti(Mit"s  skin  for  minor  siiru-ical 
operations  it  shoukl  be  woll  washed  with  soap  and  water  and 
then  ruised  ofi'  with  boiled  water  followed  1)\  alcohol,  or  it 
may  be  rapidix'  i)rei)ared  by  sim])ly  i)aintin.i!;  it  with  tinetnre 
of  iodin.  Kemember  that  after  the  hand  or  skin,  or  anything 
else  for  that  matter,  has  been  sterilized,  it  no  longer  remains 
sterile  after  it  has  been  in  contact  with  some  non-sterile 
object.  Consequentl\-  sterile  supplies  and  utensils  should 
never  be  handled  except  after  sterilization  of  the  hands. 


Fig.  159. — Arnold  sterilizer  for  use  in  private  houses  and  in  idiy.sician's 
office,     (Brewer.) 

Rubber  Gloves. — These  may  be  sterilized  either  by  boiling 
or  by  immersing  in  bichloride  of  mercury  solution  for  an 
hour  or  longer.  When  a  great  many  cases  are  being  dressed, 
as  in  the  receiving  ward  of  a  hospital,  rubber  glox'cs  may  be 
worn  and  washed  in  water  and  then  dipped  in  bichloride 
solution  between  dressings. 


DIET. 

The  diet  of  the  sick  depends  largely  ujxjn  the  orders  of 
the  physician,  in  attendance.  When  patients  are  feverish 
and  sick  and  there  has  been  no  si)ecial  diet  ordered  by  the 
physician  it  is  wisest  to  give  only  fluid  food. 


DRUGS  295 

The  forms  of  fluids  which  may  ahiiost  invariably  }>c  ^iv(;n 
without  dauber  are:  clear  broth,  boc^f  tea,  orau<i;(;-albumeu 
water,'^  tea  and  cofi'ee.  In  addition,  milk,  buttermilk,  cocoa, 
and  gruels  are  nourishing  and  seldom  harmful.  Fluids  are 
given  every  two  or  three  hours,  about  0  ounces  (a  cui)ful)  at 
each  feeding. 

During  convalescence  a  light  diet,  consisting  of  custarrls, 
soft-boiled  eggs,  well-cooked  cereals,  ice-cream,  and  milk 
toast  may  be  given. 

Especially  in  conditions  associated  with  disturbance  of  the 
stomach  or  bowels,  fried  foods,  meats,  vegetables,  pastries, 
and  raw  fruits  (except  fruit  juices)  should  be  avoided. 


DRUGS. 

While  the  administration  of  drugs  is  not  properly  a  part 
of  first  aid,  it  is  desirable  that  the  student  should  familiarize 
himself  in  the  use  of  a  few  drugs  and  solutions  commonly 
used. 

The  dosage  of  drugs  as  usually  given  is  the  adult  dose. 
If  given  to  children  the  dose  should  be  correspondingly 
smaller.  Generally  speaking,  the  adult  dose  is  given  after  the 
age  of  eighteen  years  and  the  dose  for  children  may  be 
roughly  calculated  according  to  age:  thus  if  a  child  is 
three  years  old  the  dose  is  j-^,  or  -g-,  of  the  adult  dose. 
Drugs  containing  opium  are  especially  dangerous  in  infancy 
and  old  age,  and  should  never  be  given  without  specific 
orders  from  the  physician  in  attendance. 

Stimulants. — Coffee  is  one  of  the  best  stimulants  which 
we  possess.  It  should  be  given  without  sugar  or  cream  and 
as  hot  as  can  be  borne.  Whisky  and  brandy  are  commonly 
considered  as  stimulants.  In  very  small  doses  they  may 
have  a  slightly  stimulating  effect. 

Aromatic  spirits  of  ammonia,  in  10-drop  doses,  well 
diluted  with  water,  may  be  given  every  fifteen  to  twenty 

1  This  is  made  by  mixing  the  juice  of  an  orange  with  the  white  of  an  egg 
and  adding  a  little  sugar  and  sufficient  ice-water  to  fill  a  glass.  The  mixture 
is  well  shaken  and  served  cold. 


296.  NURSING  AND  TECHNIC 

minutes  for  four  or  fi\t'  doses.     It  has  a  temporary,  mild, 
stimulating  oll'ect. 

Tincture  of  nux  vomica  contains  strychnin.  It  may  he 
given  in  10-drop  doses  three  or  four  times  daily.  Strychnin 
itself  is  a  \ery  powerful  drug  and  should  be  given  in  very 
small  doses,  not  over  ^V  gr^dn. 

Sedatives. — Sodium  bromide  is  a  .safe  form  of  sedative. 
Ten  to  21)  grains  may  be  gi\-en  and  repeated  after  a  few 
hours.  It  should  not  be  used  over  long  periods  except  under 
the  advice  of  a  physician. 

Aspirin,  5  to  10  grains,  w\\\  sometimes  quiet  nervous 
irritability  and  deaden  pain.  It  should  not  be  taken  repeat- 
edly or  more  than  twice  in  one  day. 

Cathartics. — For  active  purging  in  acute  illness  castor  oil 
is  to  be  preferred.  The  dose  is  from  1  to  2  tablespoonfuls. 
If  sufficient  is  given  the  bowels  will  move  in  from  two  to 
four  hours. 

Saline  cathartics  include  Epsom  salts,  Rochelle  salts, 
.sodium  phosphate,  and  many  others.  The  dose  is  about  one 
tablespoonful.  Seidlitz  powders,  citrate  of  magnesia,  Pluto 
water,  Apenta  water,  and  others  t)f  the  same  type  all  contain 
salts  which  have  a  cathartic  action.  They  cause  movement 
of  the  bowels  in  from  one  to  tlu-ee  hours.  The  dose  varies 
according  to  the  strength  of  the  solution. 

The  principal  vegetable  cathartics  are  aloes,  cascara,  and 
senna.  They  usually  act  after  six  to  eight  hours.  The  dose 
varies  Avith  the  drug  and  the  strength  of  the  solution  used. 

White  mineral  oil  is  a  mild  cathartic  which  is  widely  used. 
It  does  not  cause  active  catharsis  but  only  a  slight  looseness 
of  the  movement.  It  is  given  in  doses  of  1  or  2  tablespoon- 
fuls daily,  and  may  be  safely  taken  for  long  periods. 

]\lilk  of  magnesia  is  a  mild  cathartic,  which  is  especially 
useful  for  children.  One  or  2  teaspoonfuls  is  the  ordinary 
do.se  for  a  child. 

Calomel  causes  active  purging.  It  is  best  given  in  yV" 
grain  doses,  every  ten  to  fifteen  minutes,  until  a  grain  is 
taken.  A  saline  cathartic  is  usually  given  six  to  twelve  hours 
later  to  remove  the  excess  of  calomel  from  the  intestines. 

Anodynes. — These  are  drugs  which  deaden  pain.  Phenac- 
etin  (5  grains)  is  one  of  the  most  useful.     In  very  severe 


DRUGS  297 

pain  of  an  acute  character,  codein  or  paregoric  may  be 
given,  but  only  on  the  prescription  of  a  physician.  None  of 
these  drugs  should  be  used  repeatedly. 

Disinfectants  and  Antiseptics. — Disinfectants  and  antisep- 
tics have  already  been  discussed.  One  of  the  safest  of  mild 
antiseptics  which  may  be  used  for  wet  dressings,  for  wet 
compresses,  and  as  a  mild  antiseptic  for  use  in  wounds  is  a 
solution  of  boric  acid. 

Boric  Acid. — Boric  acid,  or  boracic  acid,  is  a  mild  acid 
which  comes  in  powdered  form.  A  1  per  cent,  solution  may 
be  made  by  mixing  a  rounded  teaspoonful  of  the  powdered 
drug  in  a  pint  of  boiling  water.  It  may  also  be  used  in  satu- 
rated solutions  which  contain  about  5  per  cent,  of  the  drug. 
This  is  poisonous  if  taken  internally  in  large  quantities,  but 
has  no  poisonous  effect  in  small  doses. 

Bicarbonate  of  Soda. — This  is  frequently  used  as  a  mouth 
wash.  It  is  not  antiseptic,  but  because  it  dissolves  mucus 
it  makes  an  excellent  gargle  when  mixed  with  hot  water.  A 
1  per  cent,  solution  is  made  by  dissolving  1  teaspoonful  of 
the  dry  powder  in  1  pint  of  water.  A  saturated  solution  is, 
approximately,  8  per  cent.  It  may  be  used  in  the  form  of  a 
wet  dressing  (especially  for  burns),  or  may  be  given  inter- 
nally in  doses  up  to  one  teaspoonful  of  the  powdered  soda. 

Bichloride  of  Mercury. — This  is  very  poisonous.  It  is  used 
in  solutions  of  1  to  1000  as  an  antiseptic,  but  should  never 
be  used  in  the  eyes  or  mouth.  One  7|-grain  tablet  added  to  a 
pint  of  water  makes  a  1  to  1000  solution.  If  used  for  a  wet 
dressing  it  should  be  further  diluted  to  1  to  5000. 

Bichloride  solutions  should  never  be  applied  to  an  area 
previously  painted  with  iodin,  as  the  mercury  combines  with 
the  iodin,  forming  a  very  irritating  mercuric  iodide  which 
soon  blisters  the  skin. 

As  little  as  ^o  grain  of  bichloride  of  mercury  taken 
internally  may  result  in  symptoms  of  poisoning. 

Carbolic  Acid  (Phenol).  —  This  is  a  valuable  antiseptic, 
but  is  apt  to  cause  gangrene  if  used  for  wet  dressings.  It  is 
crystalline  when  pure,  and  liquid  after  a  little  water  has  been 
added.  This  is  called  strong  carbolic  acid  (95  per  cent.). 
It  is  not  further  soluble  until  sufficient  water  has  been  added 


20S 


NCRSIXC   AXD   TECHMC 


to  make  a  5  per  cent,  solution  (dilute  earholic  acid).  Any 
strenjjth  below  5  per  cent,  can  be  obtained  by  addinji^  suitable 
amounts  of  water.    It  is  used  princii)ally  for  the  sterilization 

of  insti-iinuMits  and  supplies. 


Fig.  IGO. — Gangrene  of  the  finspr,  the  result  of  a  wet  carlicilic'  drcssint;  for 
only  twenty-four  hours.     (Ashhurst.) 

Tincture  of  lodin. — This  is  an  alcoholic  solution  of  iodin, 
and  is  in  common  use.  If  more  than  a  few  droj)s  is  swallowed 
it  is  ])oisonous.  Ordinarily  it  is  used  externally  for  counter- 
irritation  and  sterilization  of  the  skin.  Because  of  the  dan- 
ger of  causing  blisters  it  is  safer  to  dilute  the  tincture  by  add- 
\ng  an  equal  quantity  of  alcohol  when  it  is  used  on  the  skin. 
When  tincture  of  iodin  stands  for  a  long  time  the  alcohol 
evaporates,  leaving  the  iodin  in  strong  solution.  Conse- 
quently, when  an  old  tincture  is  used  alcohol  should  be  added 
until  the  stain  on  the  skin  is  only  moderately  brown.  The 
\cry  dee])  brown  stains  are  apt  to  raise  blisters. 

Emetics. — These  drugs  have  already  been  gi\en  in  the 
treatment  of  poisoning. 

Many  other  drugs,  such  as  syrup  of  ginger,  bismuth,  alum, 
spirits  of  camphor,  etc.,  may  find  occasional  use  in  first-aid 
work. 

In  using  drugs  care  should  be  taken  to  use  only  those 
which  are  comparatively  harmless  in  the  doses  given,  and 
the  uses  of  which  are  clearly  understood.  In  the  use  of  drugs, 
as  well  as  any  other  form  of  treatment,  no  remedy  should 
be  given  unless  its  use  is  well  understood  and  the  indications 
for  its  use  are  definite  and  clear.  Remember  that  the  wrong 
treatment  is  usually  worse  than  no  treatment. 


INDEX. 


Abdomen,  61 

bandage  of,  109 

contusion  of,  205 

wounds  of,  207 
Abduction  of  joint,  40 
Accident,  general  rules  for,  20 
Acid,  boric,  297 

burns,  153 

carbolic,  297 
Action,  reflex,  57 
Actual  cautery,  288 
Adduction  of  joint,  40 
Air  cells,  59 
Alcohol  baths,  281 

dressing,  85 

for  shock,  168 

for  snake  bite,  162 
AlcohoHsm,  225 
Alimentary  canal,  61 
Alkah  burns,  153 
Ambulance,  270 

improvised,  272 
Anatomy,  27 
Anemia,  44 
Ankle,  bandage  of,  100 

dislocation  of,  143 

fracture  of,  133 

sprain  of,  145 
Anodynes,  296 
Antidotes,  219 

table  of,  228 
Antiseptic,  77 
Antiseptics,  78,  297 
Antitoxin  for  tetanus,  165 
Aorta,  46,  47,  48 
Apoplexy,  196 
Appendicitis,  248 
Application  of  heat,  284 
Applications,  external,  284 
Arm,  bandage  for,  88 


Arm,  fracture  of,  128 
Army  first-aid  y)acket,  24 

litter,  256 
Arnold  sterilizer,  294 
Arteries,  46,  48 

location  of,  73 
Artery  clamps,  70 

pulmonary,  46 

radial,  48* 
Artificial  respiration,  178 
Asepsis,  77 

Asphyxiation  by  gas,  187 
Aspirin,  296 

for  headache,  237 
Auricle  of  heart,  45,  49 
Autoclave,  292 
Axilla,  bandage  of,  106 


B 

Bacilli,  75 

tetanus,  164 
Back,  sprain  of,  146 
Bacteria,  74 
Bacterial  diseases,  77 
Bandage,  application  of,  91 

Barton's,  105 

figure-of-eight,  93,  100 

four-tailed,  89 

recurrent,  101,  104 

roller,  90 

method  of  rolling,  91 

spica,  94,  95 

spiral  reverse,  93 

triangular,  86 

Yelpeau,  110 

of  wound,  85 
Bandaging,  86-110 
Barton's  bandage,  105 
Baths,  alcohol,  281 

foot,  284 


3(10 


IXDEX 


Baths,  ice,  2S2 

nHHlit'iitod,  2S4 

Sitz,  284 

sponge,  2S1 

sweat,  283 

temperature  of,  280 

till),  282 
Beii,  making  of,  27t) 

patients',  275 

sores,  277 
Bicarbonate  of  soda,  297 
Bichloride  of  mercury,  78,  297 
Bile,  (il 
Bite,  dog,  159 

insect,  U'>3 

snake,  101 
Bladder,  64 

injury  to,  208 

rui)ture  of,  (i4 
Blood  l)hster,  213 

composition  of,  43 

jwisoning,  232 
Boils,  240  ^ 
Bones  of  head,  30 

location  of,  27 

of  lower  extremity,  34 

of  upper  extremity,  32 

wounds  of,  147 
Boric  acid,  78,  297 
for  eye  wash,  240 
ohitment,  151 
Boxer's  ear,  199 
Boy  scout  first-aid  case,  25 
Brain,  53 

injury,  30 
Breast,  bandage  of,  107 
Breath,  shortness  of,  246 
Bromide  of  soda,  296 
for  epilepsy,  234 
Bronchi,  59 
Bronchioles,  59 
Bullet  wounds,  147 
liurns,  149 

chemical,  153 

ice-cap  for,  156 

infected,  152 

severe,  152 

treatment  of,  151 

a-ray,  158 


Cai^oaiel,  296 
Canal,  alimentarj',  01 


Cantharides,  290 
Capillaries,  48 
Car,  hospital,  273 
Carbolic  acid,  297 
for  bites,  160 
burns,  154 
as  disinfectant,  78 
Carbon  monoxide  jjoisoning,  188 
Carbuncle,  242 
Carinis,  (lescrii)tion  of,  33 
Carron  oil  for  burns,  151 
Castor  oil  for  convulsions,  235 
for  ptomain  poisoning,  228 
Catliartics,  29t) 

for  poisoning,  220 

vegetable,  2i)6 
Cautery,  288 

Paquelin,  288 
Caustic  acid  i)oisons,  221 

alkali  poisons,  222 
Cells,  air,  59 
Cellulitis  (jf  scalp,  193 
Cerel)e]hnn,  54 
Cerebrum,  54 
Chair  litter,  267 
Chemical  burns,  153 
Chest,  bandage  of,  IOC),  107,  109 

contusion  of,  204 

triangular  bandage  of,  87 

wounds  of,  204 
Chills,  231 

in  malaria,  232 

symptoms  of,  232 

treatment  of,  232 
Chin,  Ijantlage  for,  90 
Chloroform,  290 

for  convulsions,  233 
Choking,  184 
Circular  bandage,  109 
Circulation,  49 
Clamjis,  arterj',  70 
Clavicle,  32 

dislocation  of,  138 

fracture  of,  125 
Clot,  44 
Clotting,  45 
('oagulation,  45 
Coat  litter,  267 
Cocci,  75 

Coffee  for  shock,  168 
Cold  baths,  172 

compresses,  286 
for  throat,  243 
use  of,  240 


INDEX 


:m 


Cold  to  control  bcmorrhago,  71 

exposure  to,  154 

pack,  172 

water  coil,  172 
Colds,  243 
Colic,  248 

Collar  bone,  fracture  of,  125 
Colles's  fracture,  130 
Coma,  174 
Command  of  execution,  257 

preparation  of,  257 
Common  emergencies,  236 
Compound  fractures,  112 
Compress,  cold,  286 

use  of,  240 
Compression  of  brain,  196 
Concussion,  194 
Conjunctivitis,  239 
Contusion  of  abdomen,  205 

of  chest,  204 

of  eye,  197 
Contusions,  65 
Convulsions,  233 

in  children,  235 

from  rabies,  160 

in  tetanus,  164 
Cord,  spinal,  54 
Cords,  vocal,  59 
Corpuscles,  red,  44 

white,  44 
Cot  as  litter,  272 
Cotton,  sterilization  of,  78 
Cough,  246 
Counter-irritants,  287 
Counter-irritation    for    toothache, 

238 
Cranium,  27 
Crepitus,  115 
Croup,  244 

diphtheritic,  246 

spasmodic,  244 

tent,  245 
Crushing  injuries,  208 
Cupping,  288 
Cups,  wet,  289 


Death  from  malaria,  230 
Defoi-mity  from  fracture,  115 
Demigauntlet  bandage,  100 
Diaphragm,  60 
Diarrhea,  249 


Diet,  294 

in  al^dominal  injury,  207 
Diphtheria,  146 
Diplococci,  76 

Disability  from  fracture,  115 
Disease,  bacterial,  77 

emergency  treatment  of,  230 
Disinfectants,  78,  297 
Dislocation,  habitual,  136 

persistent,  136 

symptoms  of,  136 

treatment  of,  136 
Dislocations,  135 
Dog  bite,  159 
Doses  of  drugs,  295 
Dressings,  sterilization  of,  292 

wet,  85 
Drills,  litter,  257 
Drowning,  184 
Drugs,  295 
Dyspnea,  280 


E 


Ear,  bandage  of,  103  * 

boxer's,  199 

foreign  body  in,  200 
Earache,  239 
Ecchymosis,  65,  116 
Elbow,  bandage  of,  96 

dislocation  of,  140 

fracture  of,  127 
Electricity,  counter-irritant,  288 

injuries  by,  157 
Elevation  to  control  hemorrhage, 

71 
Emergencies,  common,  236 
Emergency  supplies,  23 

treatment  of  disease,  230 
Emetics,  298 

P^mphysema,  subcutaneous,  204 
Epiglottis,  59 
Epilepsy,  233 

symptoms  of,  234 
Epsom  salts,  296 
Equipment,  22 
Esophagus,  61 
European  War,  gas  poisoning  in, 

189 
Exhaustion  as  cause  of  shock,  166 

heat,  173 
Expiration,  60 
Exposure  as  a  cause  of  shock,  166 


302 


IXDEX 


Extension  of  joint,  40 
Kxtornal  applications,  284 
Kxtroniitics,  injuiios  to,  208 
Eye,  bandage  of,  102 
contusion  of,  1V)7 
foreifin  body  in,  IDS 
inHannnation  of,  239 
pink,  240 
wounds  of,  198 


pAINTINf;.  UiS 

False  ])oint  of  motion.  1  lo 
Feet,  rare  of,  212 
Femur,  34,  35 
Fever,  230 

symptoms  of,  231 

treatment  of,  231 
Finger  bandage,  97 

dislocation  of,  141 

fracture  of,  131 

infection  of,  81 

sjmiin  of,  146 
First-aid  case,  boy  scout,  25 

definition  of,  17 

general  i)rincii)lcs  of,  17 
rules  for,  17 

household  outfit,  25 

kits,  23 

organization,  25,  26 

outfit,  23 

packet,  U.  S.  Army,  24 

rules  for  U.  S.  Troops,  22 

squads,  25,  26 
members  of,  26 
team  work  of,  26 
Fish  hook,  injiuy  with,  23 
Fits,  233 

Flame  projectors,  191 
Flaxseed  poultice,  286 
Flexion  to  control  hemorrhage,  70 

of  joint,  40 
Foot,  bandage  of,  100 

baths,  284 

dislocation  of,  143 

fracture  of,  135 

injuries  of,  212 
Forearm,  description  of,  33 

fracture  of,  128 
Foreign  body  in  ear,  200 
in  nose,  200 
in  throat,  203 


Foreign  body  in  tissues,  211 

in  windi)ipe,  184 
Formalin  as  disinfectant,  78 
Four-tailed  bandage,  89 
'  Fracture,  comitound,  112 
j      green-stick,  112 
I      gunshot,  1 13 
j      impacted,  112 
simple,  112 
skull,  30 

symptoms  of,  1 13 
treatment  of,  1 18 
union  of,  1 17 
Fiactures,  111 
Frost-bite,  155 


G 

Gangrene,  carbolic,  85,  298 

from  cold,  150 
(largle  for  sore  throat,  243 
(ias  helmet,  ICO 

poisoning  in  war,  189 
(launtlct  bantlage,  99 
Gauze,  sterilization  of,  78 
General  rules  for  accident,  20 

for  first  aid,  17 
Glassware,  sterilization  of,  292 
Granvilation,  SO 
Green-stick  fractures,  112 
Groin,  lianrlage  of,  95 
Cndlet.  61 
Gum  l)oil,  238 
Gunshot  fractures,  113 

injuries,  209 


H 

Habitual  dislocation,  136 
Hand,  l)ones  of,  34 

infected,  83 

preparation  of,  79 
Head,  27 

bandage,  87,  103 

bones  of,  30 
Headache,  236 
Healing  of  wounds,  SO 
Heart,  45 

rate,  46 
Heat,  application  of,  284 

asepsis  by,  77 

to  control  hemorrhage,  71 


INDEX 


303 


Heat  exliaustion,  178 
Heel,  bandage  of,  101 
Helmet,  gas,  190 
Hematemesis,  202 
Hemoptysis,  202 
Hemorrhage,  67 

arterial,  68 

capillary,  67 

cause  of  shock,  166 

control  of,  68-74 

from  bladder,  208 

from  lungs,  202 

from  mouth,  201 

from  nose,  200 

from  rectum,  208 

from  stomach,  202 

from  varicose  veins,  68 

from  veins,  49 

internal,  202 

subcutaneous,  65 

venous,  68 
Hemorrhoids,  250 
Hernia,  strangulated,  207 
Hiccough,  242 
Hip,  bandage  for,  88 

dislocation  of,  143 
Hoarseness,  243 
Hospital  pouch.  Army  type,  24 

train,  272 
Hot  compresses,  285 

packs,  282 
Household  first-aid  outfit,  25 
Humerus,  32 
Hydrophobia,  160 
Hysteria,  176 


Ice  baths,  282 
Ice-bag,  287 

for  appendicitis,  248 
Ice-cap  burn,  156 
Impacted  fractures,  112 
Improvised  ambulance,  272 
Indigestion,  247 
Infection,  74 

of  finger,  81 

of  hand,  83 

of  scalp,  193 

in  war,  75 
Inferior  maxilla,  30 
Inhalations  for  croup,  245 
Injury  to  brain,  31 


Injury  cause  of  shock,  166 

to  extremities,  208 

intracranial,  195 

to  nerves,  210 
Inspiration,  60 
Instruments,   sterilization    of,    78, 

291 
Internal  hemorrhage,  202 
Intestine,  rupture  of,  64 

small,  61 
Intestines,  large,  61 
Intracranial  injury,  195 
Involuntary  movements,  51 
lodin  as  antiseptic,  78 

burns,  154 

as  counter-irritant,  287 

tincture  of,  289,  298 
Ivy  poisoning,  252 


Jaav,  dislocation  of,  141 

fracture  of,  125 
Joints,  36 

classification  of,  36 

painful,  257 

wounds  of,  147 


Kidneys,  64 
Kits,  first-aid,  23 
Knee,  bandage  of,  97 

dislocation  of,  143 
Knee-cap,  dislocation  of,  143 

fracture  of,  131 


Laryngitis,  243 

Larynx,  59 

Leg,  bandage  of,  93,  101 

bones  of,  36 

fracture  of,  132 
Leukocytes,  44 
Ligaments,  38 
Ligatures,  70 
Liniments,  290 
Litter,  blanket,  267 

chair,  267 

coat,  267 


304 


INDEX 


Litter,  description  of,  256 

drills,  257 

improvised,  206 

loaded,  261 

transportation,  256 
Liver,  61 
Lockjaw,  163 

Lower  extremity,  bones  of,  34 
Lung,  hemorrhage  from,  202 

motor,  182 
Lungs,  59 


M 

jMagnksia,  296 
Malaria,  chills  in,  232 

death  from,  230 
Mandible,  30 
Mangle  injuries,  208 
Manual,  litter  drill,  257 
Mask,  gas,  190 
Massage,  287 
Mastitis,  239 
Maxilla,  inferior,  30 
^Mechanical  respiration,  182 
Medicated  baths,  284 
Membrane,  sj-novial,  38 
Meniscus,  dislocation  of,  143 
Menthol,  290 

Mercur\-,  bichloride  of,  297 
Metacarpus,  33 
Metatarsus,  36 
Moles,  252 
Mouth,  hemorrhage  from,  201 

wounds  of,  201 
Movements,  involuntary,  51 

voluntary,  51 
Muscle,  rupture  of,  212 
Muscles,  40 

action  of,  40 

involuntary,  43 

painful,  252 

voluntary,  43 
Mustard  plaster,  286 


N 

Nail,  splinter  beneath,  213 
Nasal  passages,  58 

septum,  58 
Nausea,  247 

treatment  of,  236 


Neck,  bandage  of,  106 
Nerve  impulse,  55 
Nerves,  54 

action  of,  54 

injury  to,  210 

of  skin,  52 
Nervous  system,  51 
Neuralgia,  238 
Nose,  58 

foreign  body  in,  200 

fracture  of,  123 
Nosebleed,  200 
Nursing  mc^tliods,  275 
Nux  vomica,  296 


Oil,  mineral,  296 

of  mustard    as    counter-irritant, 

287 
Ointments,  2m 
Olive  oil  for  burns,  151 
Organization  of  first-aid,  25 
Organs,  reproductive,  64 

injury  to,  64 
Outfit,  first-aid,  23 


Packet,  first-aid,  24 

Packs,  hot,  282 

Pain  from  fracture,  113 

relief  of,  17 
Paciuelin  cautery,  288 
Paregoric  for  diarrhea,  249 

for  i)tomain  poisoning,  228 
Pasteur  treatment,  161 
Patella,  35 

dislocation  of,  143 
Pathogenic  bacteria,  74 
Pelvis,  contents  of,  31,  32 

description  of,  31,  32 
Peritonitis,  205 
I  Peritonium,  64 
j  Persistent  dislocation,  136 
Phagocytes,  44 
!  Phalanges  of  hand,  33,  34 
!      of  foot,  36 
Phenacetin,  296 

for  headache,  237 
Phenol,  297 
'      for  boils,  241 


INDEX 


305 


Phenol  as  disinfectant,  78 

Physician,  necessity  for,  19 

Physiology,  27 

Piles,  250 

Pink  eye,  240 

Plasma,  44 

Plaster,  mustard,  296 

Pneumonia,  232 

from  exposure,  230 
Poison  ivy,  252 
Poisoning,  214 

alcoholic,  225 

bicliloride  of  mercury,  224 

carbolic  acid,  222 

carbon  monoxide,  188 

chloral,  223 

chloroform,  227 

caustic  acids,  221 
alkalies,  222 

ether,  227 

mushroom,  227 

opium,  223 

phenol,  222 

ptomain,  227,  236 

strychnin,  224 

symptoms  of,  215 

treatment  of,  215 
Poisons,  table  of,  228 
Pott's  fracture,  133 
Pouch,  hospital,  24 
Poultice,  flaxseed,  286 
Pressure  for  hemorrhage,  69 
Ptomain  poisoning,  227,  236 
Pulmonary  artery,  46 
Pulmotor,  182 
Pulse,  46,  48,  279 
Pupils  in  brain  injury,  197 


R 

Rabies,  160 
Radius,  32 

Rectum,  injury  to,  208 
Recurrent  bandage,  101,  104 
Red  blood  corpuscles,  44 
Reflex  action,  57 
Repair  of  wounds,  79 
Reproductive  organs,  64,  208 
Respiration,  60,  178 

artificial,  178 

rate  of,  60,  279 
Respiratory  system,  58 
Ribs,  description  of,  31 


Ribs,  fracture  of,  125 

Rochellc  salts,  296 

Roller  bandage,  90 

Rubber,  sterilization  of,  294 

Rubefacients,  287 

Rules  for  first  aid,  U.  S.  Troops,  22 

Rupture  of  muscle,  212 

of  tendon, 210 

of  varicose  vein,  21 


Saline  cathartics,  296 
Salts,  Epsom,  296 

for  ptomain  poisoning,  228 

Rochelle,  296 
Scalp,  bandage  of,  87,  90 

infection  of,  193 

wounds,  193 
Scapula,  32 

description  of,  32 
Schaefer,  artificial  respiration,  179 
Sedatives,  296 
Septum,  nasal,  58 
Serum,  44 

Sheets,  changing  of,  276 
Shock,  166 

electric,  157 

symptoms  of,  166 

treatment  of,  167 
Shoes  to  prevent  foot  injuries,  212 
Shoulder,  dislocation  of,  138 
Shrapnel  wounds,  209 
Sick  room,  257 

preparation  of,  275 
Simple  fractures,  1 12 
Sitz  baths,  284 
Skeleton,  27 
Skin,  care  of,  276 

preparation  of,  294 
Skull,  fracture  of,  30,  121 
Sling  for  arm,  88 
Smoke,  suffocation  by,  187 
Snake  bite,  161 
Sodium  bicarbonate,  297 

bromide,  296 
Solutions,  steriUzation  of,  291 
Sore  throat,  242 
Spasmodic  croup,  244 
Spasms,  233 
Special  senses,  51 
Spica  of  groin,  95 
Spinal  column,  31 


;joi) 


IXDEX 


S])iii;il  conl,  ")■} 

Spine,  ilislocation  of,  \'A7 

frarturc  dI',  121 
Splintor,  reiiioval  of,  211,  21  o 
yjilints,  liandagc  for,  b!5 

for  fractiuT.  119 
Sponiio  1  laths,  281 
Sprains,  144 
Staphylococci,  "(i 
Sterilization,  291 
oi  cotton.  Is 
of  f^au/.e,  7S 
of  instruments,  7S 
Sterilizer,  Arnold,  21)4 

improvised,  292 
Stimulants,  295 
StinuUation  for  shock,  U'S 
Stomach,  hemorrhage  from,  202 

tui:e,  21G 
Strain,  211 

Stranjiulatcil  hernia,  207 
Streptococci,  75 
Stretcher  (see  Litter) 
Strychnin,  296 
Stumj),  bandage  of,  101 
Stupes,  2S5 

turpentine,  285 
Stye,  240 
Styptics,  74 

Subcutaneous  emi)hysema,  204 
Suffocation,  177 
Sunstroke,  170 
symptoms  of,  171 
treatment  of,  171 
Supplies,  22 

emergency,  22 
Supjjuration,  74 
l)actcria  in,  76 
Sweat  baths,  283 

Sylvester,  artificial  respiration,  ISO 
Syncope,  168 
Synovial  membrane,  38 
Synovitis,  38 
System,  nervous,  51 
resjiiratory,  58 


Table   of   poisons   and   antidotes, 

Tarsus,  36,  37 
Temperature,  277 
in  sunstroke,  170 


Tendon,  action  of,  40 
rupture  of,  210 
wounds  of,  210 
'i'ent,  croup,  245 
Tetanus,  163 

treatment  of,  165 
Thermometer,  clinical,  278 
Thigh,  fracture  of,  131 
Throat,  foreign  body  in,  203 

infhunmation  of,  242 
Tlunnb,  dislocation  of,  141 

sprain  of,  146 
Til)ia,  34 

Tincture  of  iodin,  289,  298 
Toe-nail,  ingrowing,  213 
Toes,  dislocation  of,  143 
Tongue,  condition  of,  280 
Tonsillitis,  242 
Tooth,  ulcerated,  238 
I  Toothache,  237 
Tourniciuet,  71 
application  of,  72 
dangers  of,  72 
I      for  snake  bite,  162 
;      improvised,  72 
to  improvise,  89 
wrongly  applied,  68 
Towels,  sterilization  of,  292 
I'rachca,  59 
Train,  hosjiital,  272 

trans])ortation,  272 
Transportation,  255 
train,  272 
water,  274 
wheel,  270 
Travois,  269 
Treatment,  emergency,  230 

^  Pasteur,  161 
Triangidar  bandage,  86 
Trunk,  31 
Tub  baths,  282 
Turjientiiie  stupes,  285 

U 

'  Ulcehated  tooth,  238 
rina,  32 
Tnconsciousness,  174 

from  shock,  166 
Union  of  tract  in-{\  1 17 
Upper  extremity,  bones  of,  32 
Ureter,  64 

Urine,  cxx-retion  of,  64 
U.  S.  rules  for  sanitary  troops,  22 


INDEX 


:i()7 


Valves  of  heart,  46 

Varicose  vein,  hemorrliage  from,  G8 
rupture  of,  21 

Vegetable  cathartics,  26(5 

Vein,  varicose,  hemorrhage  from,  68 

Veins,  48 

hemorrhage  from,  49 

Velpeau  bandage,  110 

Ventilation  of  room,  275 

Ventricle  of  heart,  45,  49 

Vesicants,  287 

Vocal  cords,  59 

Voluntary  movements,  51 

Vomiting,  247 
of  blood,  202,  206 
to  remove  poisoning,  216 


W 

War,  wounds  in,  75 

Warts,  252 

Water  transportation,  274 

Wet  dressings,  85 

Wheel  transportation,  270 


White  blood  corpuscl(!s,  ruiicfion  of, 

44 
Wounds,  65,  66 

of  abdomen,  207 

about  eye,  198 

of  chest,  204 

contused,  66 

examination  of,  20 

healing  of,  80 

incised,  66 

infected,  81,  84 

lacerated,  66 

of  mouth,  201 

punctured,  66 

repair  of,  79 

scalp,  195 

shrapnel,  209 

tendons,  210 

treatment  of,  66,  82 
Wrist,  dislocation  of,  141 

sprain  of,  146 


X-RAYS  for  fracture,  117 


iKiii-aK5'^"v' 


~2:>^^ 


% 


